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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
304312995
Report Date:
01/30/2024
Date Signed:
01/30/2024 03:05:14 PM
Document Has Been Signed on
01/30/2024 03:05 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
ORANGE COUNTY CC RO
,
750 THE CITY DRIVE, SUITE 250
ORANGE
,
CA
92868
FACILITY NAME:
TRIVEDI, BHRUGESH
FACILITY NUMBER:
304312995
ADMINISTRATOR:
TRIVEDI, BHRUGESH
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
(714) 366-0979
CITY:
YORBA LINDA
STATE:
CA
ZIP CODE:
92886
CAPACITY:
14
TOTAL ENROLLED CHILDREN:
14
CENSUS:
0
DATE:
01/30/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
02:40 PM
MET WITH:
Jayshree Trivedi - Licensee's Mother
TIME COMPLETED:
03:15 PM
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On 1/30/24 at 2:40pm an unannounced visit was conducted by Licensing Program Analyst (LPA) Anna Chan. Upon arrival LPA met with licensee's mother Jayshree Trivedi. Licensee was not at the facility at this time. LPA spoke with licensee on the phone and licensee stated that facility is still inactive. Licensee stated he would like to be placed on inactive status still and will settle the balance to make fees current. Currently there are no children in the facility and none was observed during the visit.
Licensee has requested to be placed on Inactive Status due to licensee has another job. Licensee stated he will email a copy of Inactive Status form to LPA.
Notice of Site visit was printed during this visit.
End of Report
SUPERVISORS NAME
:
Martha Malane
LICENSING EVALUATOR NAME
:
Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE
:
DATE:
01/30/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/30/2024
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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