<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 233008242
Report Date: 08/28/2024
Date Signed: 08/28/2024 02:18:16 PM

Document Has Been Signed on 08/28/2024 02:18 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/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
08/28/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:52 PM
MET WITH:Tonya StultzTIME VISIT/
INSPECTION COMPLETED:
02:33 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Robert Maciel made a visit for the purpose of following up on a plan of correction and met with Licensee, Tonya Stultz. On 05/15/24, the facility was cited for the an uncleared adult residing in the home.

During today's visit at 1:57 PM, Licensee showed LPA a document for Adult 1 (A1) proving fingerprint clearance and association to the facility. Also, Licensee gave LPA an updated application removing Licensee Daniel Stultz from the License.

Report was read and reviewed with the licensee, Tonya Stultz. A notice of site visit given and must remain posted for 30 days. Failure to do so will result in an immediate civil penalty of $100. No deficiencies were cited during today's visit.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
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 1