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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483008850
Report Date: 03/11/2025
Date Signed: 03/11/2025 04:08:09 PM

Document Has Been Signed on 03/11/2025 04:08 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 CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ROERDEN, ALLISON FAMILY CHILD CARE HOMEFACILITY NUMBER:
483008850
ADMINISTRATOR/
DIRECTOR:
ROERDEN, ALLISONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 718-7505
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 14TOTAL ENROLLED CHILDREN: 19CENSUS: 11DATE:
03/11/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:06 PM
MET WITH:Allison RoerdenTIME VISIT/
INSPECTION COMPLETED:
03:42 PM
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A Case Management inspection was conducted at the facility by Licensing Program Analyst (LPA) Y. Yang in response to an Unusual Incident Report (UIR) received 02/28/2025 involving a child sustaining a head injury while in care. During today’s visit, the LPA met with the facility’s licensee, Allison Roerden to discuss the incident and obtain additional details. The licensee reported that on 02/28/25, child C1 was playing in the home’s on limits backyard and tripped on a paver stone in the ground and hit their head on a piece of wooden landscape edging. The licensee stated that there was a wound on C1’s head, which was cleaned and first aid was applied. The licensee stated that C1’s authorized representative was notified immediately; C1’s authorized representative transported C1 to be examined by a medical professional. The licensee stated that C1’s authorized representative notified her that C1 did not sustain a concussion but did have glue applied to the wound.

During today's case management visit, the LPA reviewed with the licensee the facility's child supervision policies. The LPA inspected the outdoor play area and did not observe any hazardous items or conditions. The LPA also observed that there is sufficient wood chip cushioning material in areas with equipment that requires fall protection cushioning. This incident was reported to CCLD and the child’s authorized representative as required per regulations.

Based on available information, it has been determined that there was no evidence of violations of regulations that occurred that lead to the child's injury. This report was read and reviewed with the licensee, Allison Roerden. There were no Title 22 violations cited during today's case management visit. The Notice of Site Visit shall be posted for 30 days.

SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Yang Yang
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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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