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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 173010444
Report Date: 07/25/2024
Date Signed: 07/25/2024 10:33:56 AM

Document Has Been Signed on 07/25/2024 10:33 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:HERNANDEZ, NORMA FCCHFACILITY NUMBER:
173010444
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
07/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:01 AM
MET WITH:Norma HernandezTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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On 04/09/2023, Licensing Program Analyst (LPA), Sebastian Phouthaovong made an unannounced Case Management visit to follow up on an Unusual Incident Report (UIR) notified to the department on 07/19/2024 LPA met with Licensee, Norma Hernandez and spoke with her the regarding the UIR.

During today's inspection, LPA toured the facility inside and out and observed 6 children being supervised by Licensee. Licensee reviewed the requirements for an Unusual Incident Report and Licensee submitted a written UIR to LPA.

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 facility representative, Norma Hernandez

There were no Title 22 deficiencies cited during today's inspection.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2024
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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