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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406216482
Report Date: 11/07/2023
Date Signed: 11/08/2023 12:40:31 PM

Document Has Been Signed on 11/08/2023 12:40 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
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:ZACHMANN FAMILY CHILD CAREFACILITY NUMBER:
406216482
ADMINISTRATOR:ALYCIA ZACHMANN / LEGALFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 458-6089
CITY:ARROYO GRANDESTATE: CAZIP CODE:
93420
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
11/07/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Alycia ZachmannTIME COMPLETED:
12:30 PM
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On 11/7/23, Licensing Program Analysts (LPAs) Elvin Baddley and Francisca Velazquez conducted an announced Case Management Inspection to deliver the Stipulation and Waiver;and Order in the matter of Respondent Alycia Zachmann (AKA Alycia Martindelcampo- CDSS No. 6422215101C, CDSS 6422215101E, OAH 2023030266) as ordered on 7/17/23. LPAs informed Applicant Alycia Zachmann of the nature and purpose of the inspection. LPAs notes one child (biological) is on site at the time of the inspection.

LPAs provided Applicant the noted Stipulation and Waiver;and Order. The Order was reviewed and limitations and conditions were discussed. LPAs further explained the noted Stipulation and Waiver;and Order Indicating the Department's intent to afford the Applicant a Probationary Licence with limitations and conditions shall be provided to the parent/guardian of any currently enrolled child by the next business day or immediately upon return as well as the parent/guardian of any enrolled child until the termination of the Probationary period.

In addition to the the noted Stipulation and Waiver;and Order, LPAs provided the Applicant an Acknowledgement of Receipt of Licensing Reports form (LIC 9224), along with a copy of Appeal Rights (LIC 9058).

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Elvin Baddley
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2023
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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