Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198013326
Report Date: 12/02/2016
Date Signed 12/02/2016 03:33:28 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:DAVIS FAMILY CHILD CAREFACILITY NUMBER:
198013326
ADMINISTRATOR:DAVIS, ELAINE & WENDELLFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 805-0005
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY:14CENSUS: 5DATE:
12/02/2016
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Elaine DavisTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Adriana Hernandez conducted a case management site visit to amend report made on 07/26/2016.

On this visit, Licensee was present with assistant Marshawn (grandson) and 5 children. Spouse who is considered co-licensee Wendell Davis, was present as well however, left at approximately 2:35pm to pick up children from school.

Amended reports reviewed, signed, and copy was provided to Licensee.

The Notice of Site Visit (LIC 9213)must remain posted for 30 days during the hours of operation after each site visit by a licensing reprehensive. Failure to maintain posting as required will result in a civil penalty of $100.00.

Exit interview was conducted with Licensee. Appeal rights explained & provided.
SUPERVISOR'S NAME: Cassandra CooperTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Adriana HernandezTELEPHONE: 323-981-3431
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2016
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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