Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 203806650
Report Date: 06/26/2015 12:00:00 AM
Date Signed 06/26/2015 11:09:21 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 E.SHAW AV,STE 300-MS 29-01
FRESNO, CA 93710
FACILITY NAME:URIBE, EVA FAMILY CHILD CAREFACILITY NUMBER:
203806650
ADMINISTRATOR:URIBE, EVAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(559) 664-0747
CITY:MADERASTATE: CAZIP CODE:
93638
CAPACITY:14CENSUS: 4DATE:
06/26/2015
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:EvaTIME COMPLETED:
11:00 AM
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(1) An unannounced annual/random visit is made today. A tour of the home, inside and outside, as shown on the facility sketch is provided. Staff and Children were spoken to during visit. Licensee has one small dog at this time. Licensee is aware that constant visual supervision is required when children have access to pets. There are no "bodies of water" or firearms in this home. Poisons, cleaning compounds, medications and other hazardous items are inaccessible to children. There is no fireplace. There is a working fire extinguisher, a smoke detector and there is adequate heating and ventilation for safety and comfort. There are no stairs in the home. Safe toys and play equipment are observed. There is a working telephone. Adequate supervision is being provided during this visit. Children are supervised when outside in the play area. Capacity as specified on the license is being maintained. Licensee has necessary information to contact parents in an emergency. All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home. Pediatric CPR/First Aid are current. During the exit interview, the licensee confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.

Per Chapter 3, Division 12, Title 22 of the California Code of Regulations no deficiencies are observed today.
SUPERVISOR'S NAME: Valarie ReedTELEPHONE: (559) 243-8093
LICENSING EVALUATOR NAME: Rusty WilsonTELEPHONE: (559) 341-4725
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2015
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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