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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
354417600
Report Date:
12/08/2022
Date Signed:
12/09/2022 01:23:55 PM
Document Has Been Signed on
12/09/2022 01:23 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
,
2580 N FIRST STREET, STE. 300
SAN JOSE
,
CA
95131
FACILITY NAME:
CONTRERAS, TERESA
FACILITY NUMBER:
354417600
ADMINISTRATOR:
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
CITY:
STATE:
ZIP CODE:
CAPACITY:
8
TOTAL ENROLLED CHILDREN:
8
CENSUS:
2
DATE:
12/08/2022
TYPE OF VISIT:
Case Management - Other
ANNOUNCED
TIME BEGAN:
03:35 PM
MET WITH:
Teresa Contreras
TIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Deanna Villagrana met with applicant Teresa Contreras to deliver and amended report for the pre licensing report conducted on 11/03/2022. Present were applicant with her three year old daughter and her brother in law with his one year old son.
Pre licensing report page 1 was not signed by applicant and page 3 was not signed by LPA. LPA had applicant sign report. There are no deficiency cited during todays visit.
Application is pending manager's approval.
SUPERVISORS NAME
:
Mary Segura
LICENSING EVALUATOR NAME
:
Deanna Villagrana
LICENSING EVALUATOR SIGNATURE
:
DATE:
12/08/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
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