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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009483
Report Date: 08/28/2023
Date Signed: 08/28/2023 12:26:17 PM

Document Has Been Signed on 08/28/2023 12:26 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:HERNANDEZ, LORENA FCCHFACILITY NUMBER:
483009483
ADMINISTRATOR:HERNANDEZ, LORENAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 712-1498
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
08/28/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:49 AM
MET WITH:Licensee Lorena HernandezTIME COMPLETED:
12:30 PM
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Licensing Program Anaylst ( LPA ) Elpidia Hernandez Torres arrived to the facility to conduct a Plan of Correction visit ( POC) for deficiencies issued in June during an annual inspection. Previously 6 children had incomplete packets missing immunizations, emergency cards, and infant in care was missing LIC 9227. All children previously missing immunztions and blue CDPH 286 have them on file with required immunizations. All children have completed emergency cards LIC 700, and infant in care has required LIC 9227 with sleep log documented.

Before leaving LPA reminded licensee the required forms needed on file for staff and assistants and gave licensee a copy of LIC 126.

Deficiencies previously issued have been cleared as of 08/28/2023.
Exit interview conducted and report was reviewed with the Licensee . A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. There were no violation observed during today’s visit.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2023
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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