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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 173010039
Report Date: 02/05/2025
Date Signed: 02/05/2025 11:41:29 AM

Document Has Been Signed on 02/05/2025 11:41 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:HANSON, SARA FCCHFACILITY NUMBER:
173010039
ADMINISTRATOR/
DIRECTOR:		HANSON, SARAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 245-5225
CITY:KELSEYVILLESTATE: CAZIP CODE:
95451
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
02/05/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:01 AM
MET WITH:Sara HansonTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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An inspection was conducted at the facility by Licensing Program Analysts, Sebastian Phouthavong. LPA met with Licensee, Sara Hanson. During the inspection the home was toured inside and outside. The licensee was supervising and assistant were supervising nine children and operating within the licensed capacity and ratio requirements.

During the inspection, LPA observed one infant child, napping in a separate room with the door closed while Licensee was stationed in the front yard with other children. According to California Code of Regulations 102425 Infant Safe Sleep, If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the Licensee, Sara Hanson

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE: DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2025
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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Document Has Been Signed on 02/05/2025 11:41 AM - It Cannot Be Edited


Created By: Sebastian Phouthavong On 02/05/2025 at 10:57 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HANSON, SARA FCCH
FACILITY NUMBER: 173010039

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/26/2025
Section Cited
CCR
102425(5)

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(5) If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times. This requirement is not met as evidenced by:
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Licensee was provided a copy of 102425 Infant Safe Sleep Regulations. Also, Licensee stated she will submit a written plan to ensure the facility is following requirements, including Licensee’s signature and date. Licensee will submit the plan to the department within 02/26/2025.
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Based on LPA's observation, one infant was observed napping in a separate room with the door closed while Licensee was stationed in the front yard which poses a potential health, safety, or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Leslie Lepori
LICENSING EVALUATOR NAME:Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE:
DATE: 02/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2025


LIC809 (FAS) - (06/04)
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