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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009483
Report Date: 02/21/2024
Date Signed: 02/21/2024 11:54:04 AM

Document Has Been Signed on 02/21/2024 11:54 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
SANTA ROSA CC RO, 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: 16CENSUS: 3DATE:
02/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Lorena HernandezTIME COMPLETED:
11:55 PM
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On 02/21/24 an unannounced Case Management visit was made by Licensing Program Analyst (LPA), Cindy Castro, in response to Unusual Incident Report (UIR) that occurred on 02/15/24. LPA met with licensee and Staff S1- S2. The licensee self-reported the incident and submitted a UIR to the Department on 02/20/24. Additional follow-up is needed.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Cindy Castro
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2024
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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