Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 203806650
Report Date: 01/18/2018
Date Signed 01/18/2018 11:38:33 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
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: DATE:
01/18/2018
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Licensee, Eva UribeTIME COMPLETED:
11:50 AM
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On this date LPA Kathie Campbell conducted a Case Management inspection. Met with licensee, Eva Uribe and a tour of the facility was made. Census was taken. The purpose of this visit is to obtain signatures and deliver an amended report.

Per California Code of Regulations, Title 22, Division 12, Chapter 1 no deficiency are cited during today's visit.

An exit interview was conducted with licensee, Eva Uribe. A Notice of Site Visit Form was posted on parent's board and must remain posted for 30 days.
SUPERVISOR'S NAME: Duane MatsubaraTELEPHONE: (559)650-7855
LICENSING EVALUATOR NAME: Kathie CampbellTELEPHONE: (559) 341-4724
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2018
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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