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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 173010676
Report Date: 05/21/2024
Date Signed: 05/21/2024 09:12:55 AM

Document Has Been Signed on 05/21/2024 09:12 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:PISENO, STEPHANIE & JUAN FCCHFACILITY NUMBER:
173010676
ADMINISTRATOR/
DIRECTOR:		STEPHANIE & JUANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 718-6353
CITY:CLEARLAKESTATE: CAZIP CODE:
95422
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
05/21/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Stephanie Piseno TIME VISIT/
INSPECTION COMPLETED:
09:30 AM
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Licensing Program Analyst (LPA) Sebastian Phouthavong arrived to conduct a change of location prelicensing inspection. An application was received to the department on 05/02/2024 for the change of location. An approved fire clearance was conducted 05/17/2024. Services will be available Monday - Friday, 7:00 AM - 5:30 PM & 9:30AM to 6:30PM. The licensee understands that 24hr consecutive care is prohibited. There are currently three adults living in the home.

During the inspection the home was toured inside and outside. The floor plan submitted by the licensee was reviewed and verified. The children will have access to the back area of the garage/studio room including its bathroom and the main home's kitchen, living room, laundry room, back bathroom, backyard and front yard. The off-limits areas include all the bedrooms and front section of the garage. The off-limits areas of the home will be inaccessible by door locks, plastic doorknob covers and/or child gates.

There are no poisons in the home and the regulation that poisons are to be locked using a key or combination lock was reviewed. Licensee stated to have no firearms or any other dangerous weapons in the home and any were observed during today's inspection. LPA observed the fireplace to be screened and inaccessible to daycare children. There is a functioning smoke detector and carbon monoxide detector. The fire extinguisher is rated at 2A10BC. First aid supplies will maintained at the facility at all times. The home's yard is fully fenced. There were no pools or other bodies of water observed.

Once Licensee has completed making the home available for daycare and have submitted the required documents to the department, the relocation will be approved.

Exit interview conducted and report was reviewed with the Licensee, Stephanie Piseno.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE: DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2024
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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