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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 354414124
Report Date: 11/04/2021
Date Signed: 11/04/2021 11:13:33 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/04/2021 11:13 AM - 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:VASQUEZ, COLLEENFACILITY NUMBER:
354414124
ADMINISTRATOR:VASQUEZ, COLLEENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 524-3098
CITY:HOLLISTERSTATE: CAZIP CODE:
95023
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
11/04/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Colleen VasquezTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Deanna Villagrana met with licensee Colleen Vasquez for a required one year visit. LPA explained the nature of the visit. Present was licensee.

Licensee states she has not had children since March 13, 2020. She states she is not opening due to the pandemic and unsure what day she will begin to care for children. Licensee requested to go inactive from today 11/04/2021-11/04/2022. LPA observed the home is following Title 22 regulations. Licensee's CPR/First Aid expires 06/14/2023 and completed Mandated Reporter training on 12/19/2019. LPA observed a full 3A40BC fire extinguisher. Licensee understands the conditions of being inactive and understands a licensing visit is needed prior to opening.

No deficiencies were cited.

A Notice of Site was issued and must be posted for 30 days.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2021
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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