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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300612717
Report Date: 01/29/2024
Date Signed: 01/29/2024 12:20:34 PM

Document Has Been Signed on 01/29/2024 12:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:DAVIES, DIANAFACILITY NUMBER:
300612717
ADMINISTRATOR:DAVIES, DIANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 413-7497
CITY:IRVINESTATE: CAZIP CODE:
92614
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
01/29/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Licensee, Diana DaviesTIME COMPLETED:
12:30 PM
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An inspection was conducted at the facility by Licensing Program Analyst (LPA) Nguyen. The purpose of this inspection was to conduct an Annual Random inspection. Upon arrival LPA met with licensee, Diana Davies. LPA observed no children during today's inspection. Licensee stated she wants to be inactive as of 01/29/2024 to 01/29/2025. LPA obtained the LIC9211.

An exit interview conducted with licensee, Diana Davies. Appeal Rights were explained. The Licensee was provided a copy of appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above. The Notice of Site Visit was provided.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Cindy Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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