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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009483
Report Date: 09/11/2023
Date Signed: 09/11/2023 12:39:30 PM

Document Has Been Signed on 09/11/2023 12:39 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: 1DATE:
09/11/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:07 PM
MET WITH:Assistant CarolinaTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Elpidia Hernandez Torres arrived to the facility to conduct a case management visit to verify the day care was closed as Licensee was on vacation. LPA arrived at 12:07 PM and observed the sign posted on the front window stating the day care was closed Friday September 05th- Friday September 22nd. LPA observed an adult with a child in the home. Adult is the assistant of Licensee and was providing care for the licensee's own child. LPA toured the home, there were no other children present. Assistant reported the day care is closed, no other day care children are present, and will not be returning until Licensee returns.

There were no title 22 deficiencies observed. Notice of site visit shall be posted for 30 days.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2023
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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