Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312394
Report Date: 10/07/2015
Date Signed 10/07/2015 03:30:31 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:LEDESMA, ASCENCION & AREVALO, ROBERTOFACILITY NUMBER:
304312394
ADMINISTRATOR:LEDESMA, ASCEN & AREV, ROBFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 533-0838
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY:14CENSUS: 7DATE:
10/07/2015
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:12 PM
MET WITH:Ascencion Ledema and Roberto ArevaloTIME COMPLETED:
04:00 PM
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Lpa Nevarez-Martinez met with both licensees who were in the home at time of visit. Lpa took census of 7 children 1 infants and 6 toddlers.

Lpa made visit to above facility in order to verify that the unpermitted patio which had been enclosed at time of visit. had been taken down.

Lpa spoke with The City of Anaheim who stated that the patio had been taken down and needed to be verified. Lpa finds that licensee has taken down his patio and property was restored to original plan.

Exit interview conducted and copy of report issued at time of visit.
SUPERVISOR'S NAME: Dana WilliamsonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Maria NevarezTELEPHONE: (714) 703-2825
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2015
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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