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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 233008242
Report Date: 08/29/2023
Date Signed: 08/29/2023 04:05:00 PM

Document Has Been Signed on 08/29/2023 04:05 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:STULTZ FAMILY CHILD CARE HOMEFACILITY NUMBER:
233008242
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 4DATE:
08/29/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:31 PM
MET WITH:Tonya StultzTIME COMPLETED:
04:19 PM
NARRATIVE
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On 8/29/23 Licensing Program Analyst (LPA) Robert Maciel conducted a case management visit for the purpose of delivering a citation due to interviews which revealed that Child 1 gained access to a cat litter box in the bathroom while unsupervised.

The following deficiencies of the California Title 22 Code of Regulations were cited. Please see LIC 809-D. Appeal rights were provided. Exit interview was conducted with Licensee, Tonya Stultz.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2023
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 2
Document is an Amendment of Original Document on 09/20/2023 10:15 AM


Created By: Robert Maciel On 08/29/2023 at 03:35 PM
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: STULTZ FAMILY CHILD CARE HOME
FACILITY NUMBER: 233008242

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/12/2023
Section Cited
CCR
102417(a)

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The licensee shall be present in the home and shall ensure that children in care are supervised at all times...
This requirement is not met as evidenced by:
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Licensee stated that she would install a hook latch onto the bathroom door and send a picture of it installed to LPA by email. robert.maciel@dss.ca.gov
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Based on interview, the licensee stated that a child was able to enter the bathroom without the licensee's knowledge which poses a potential health, safety or personal rights risk to persons in care. 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:Alexis Hollon
LICENSING EVALUATOR NAME:Robert Maciel
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2