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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343622567
Report Date: 06/30/2022
Date Signed: 06/30/2022 11:45:15 AM

Document Has Been Signed on 06/30/2022 11:45 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:PETTY, KARENFACILITY NUMBER:
343622567
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
06/30/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Karen PettyTIME COMPLETED:
12:00 PM
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At 11:00 am on June 30, 2022 Licensing Program Analyst Lea Habtom met with licensee, Karen Petty, for an unannounced case management visit. The purpose of today's visit is to confirm licensee had the adults in the home fingerprinted and to get a signature on the form LIC 421BG for a penalty that was issued on June 23, 2022. LPA L. Habtom was unable to clear the deficiency cited for fingerprints because one set of fingerprints has not completed processing. During the inspection, licensee's tenants were at the main home and no kids were present. LPA Habtom provided a notice of site visit to be posted for 30 days.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Lea Habtom
LICENSING EVALUATOR SIGNATURE: DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2022
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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