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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 173010842
Report Date: 03/28/2025
Date Signed: 03/28/2025 02:11:32 PM

Document Has Been Signed on 03/28/2025 02:11 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:WICHLAZ, HEATHER FCCHFACILITY NUMBER:
173010842
ADMINISTRATOR/
DIRECTOR:		HEATHER WICHLAZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 349-8981
CITY:KELSEYVILLESTATE: CAZIP CODE:
95451
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
03/28/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:52 PM
MET WITH:Heather WichlazTIME VISIT/
INSPECTION COMPLETED:
01:53 PM
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*****The change of location pre licensing inspection was conducted on 03/27/2025. During the visit, LPA was not able to create a LIC 809 Report under the facility license and was recreated on 03/28/2025. The language below has not be altered from it original LIC 809 Report. Licensee, Heather Wichlaz.'s original signature is on file*****

On 03/27/2025 at 11:00AM, Licensing Program Analyst (LPA) Sebastian Phouthavong arrived to conduct a change of location pre licensing inspection. An application was received to the department on 03/12/2024 for the change of location. An approved fire clearance was conducted 03/25/2025. Services will be available Monday - Friday, 6:00 AM - 6:00 PM. The licensee understands that 24hr consecutive care is prohibited. There are currently three adults living in the home.

Due to technical difficulties, LPA could not created a LIC 809 Report under the Facility License: 173010842 and was created under the facility License: 173010643. The change of location pre licensing inspection was conducted at Gray Stone Court, Kelseyville location.

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 living room, playroom, kitchen, hallway bathroom, laundry room, porch, backyard, side yards and front yard. The off-limits areas include master bedroom including one bathroom and 2 other bedrooms. The off-limits areas of the home were made inaccessible by door locks, plastic doorknob covers and/or child gates.

There are poisons in the home's shed and is meet requirements as of today's visit. The regulation that poisons are to be locked using a key or combination lock was reviewed. The firearms and ammunition are locked and separated from each other, meeting requirements.
NAME OF LICENSING PROGRAM MANAGER: Leslie Lepori
NAME OF LICENSING PROGRAM ANALYST: Sebastian Phouthavong
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WICHLAZ, HEATHER FCCH
FACILITY NUMBER: 173010842
VISIT DATE: 03/28/2025
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There is a functioning smoke detector and carbon monoxide detector and 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.

The facility is approved for licensure effective today, March 27, 2025

Exit interview conducted and report was reviewed with the Licensee, Heather Wichlaz.
NAME OF LICENSING PROGRAM MANAGER: Leslie Lepori
NAME OF LICENSING PROGRAM ANALYST: Sebastian Phouthavong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
LIC809 (FAS) - (06/04)
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