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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430753723
Report Date: 09/14/2023
Date Signed: 09/14/2023 12:45:37 PM

Document Has Been Signed on 09/14/2023 12:45 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:MASON, IRENE & RODNEYFACILITY NUMBER:
430753723
ADMINISTRATOR:MASON, IRENEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 847-8698
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 14TOTAL ENROLLED CHILDREN: 2CENSUS: 0DATE:
09/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:Irene and Rodney MasonTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Required-1 Year inspection. LPA met with Licensee Rodney and Irene Mason and explained the reason for the inspection. There were no children present during today's inspection. Licensee Irene stated that she only cares for her own school-age grandchildren.

During today's inspection, LPA toured the inside and outside of the home with Licensee Irene.

Licensee submitted closure letter during today's inspection. Licensee will be closing as of 09/14/2023.

No deficiencies were issued as a result of this inspection. Exit interview conducted and report was reviewed with Licensee Irene Mason.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2023
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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