<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483010826
Report Date: 02/12/2026
Date Signed: 02/12/2026 04:36:45 PM

Document Has Been Signed on 02/12/2026 04:36 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:WILLIAMS, SYMONE FCCHFACILITY NUMBER:
483010826
ADMINISTRATOR/
DIRECTOR:		SYMONE WILLIAMSFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 606-8980
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 14TOTAL ENROLLED CHILDREN: 7CENSUS: 2DATE:
02/12/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Symone WilliamsTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
An unannounced annual inspection was made to the facility by Licensing Program Analyst (LPAs), Dianne Morrison. LPA met with Licensee, Symone Williams (LS). LS was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

During the inspection the home was toured inside and outside. The licensee was supervising 2 children, operating within the licensed capacity and ratio requirements. LS provided a current roster of children in care as required. LPA verified that the children present were listed on the roster. The facility’s operating hours are Sunday through Saturday, 12:00 a.m. – 11:59 p.m. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas are: two bedrooms, laundry room, kitchen, and a storage room. These areas have been made inaccessible by means of door locks, child safety gates, and doorknob covers. The home does not have any staircases and the home's gas fireplace has a panel covering the fireplace.

During the tour of the inside of the facility, LS did not have a crib or play yard, but will be providing care for infants. LS immediately ordered a play yard and had it delivered while LPA was in the facility. The children use the fully fenced backyard as the outdoor play area. There were no swimming pools or other bodies of water observed on the property. The home appears to be clean and orderly and was at a comfortable indoor temperature. LPA observed safe toys and equipment available for children. There is also a working telephone in the home.

LS’s pediatric CPR and First Aid certifications were reviewed and expire on 08/2026. Mandated Reporter Training certificate was reviewed and expires on 08/2026.

Continued on LIC 809-C.

NAME OF LICENSING PROGRAM MANAGER: Melinda Mohr
NAME OF LICENSING PROGRAM ANALYST: Dianne Morrison
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 7
Document Has Been Signed on 02/12/2026 04:36 PM - It Cannot Be Edited


Created By: Dianne Morrison On 02/12/2026 at 02:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WILLIAMS, SYMONE FCCH
FACILITY NUMBER: 483010826

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(a)
Infant Safe Sleep
(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in that she did not have a crib or play yard in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2026
Plan of Correction
1
2
3
4
LS will purchase a play yard to have on hand when she does have an infant under 12 months in her care.
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in two out of two children's records. LS did not have immunization records available for C1-C2 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2026
Plan of Correction
1
2
3
4
Obtain immunization records for children C1 - C2 and provide proof of immunizations and CDPH 286 to LPA: dianne.morrison@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Melinda Mohr
NAME OF LICENSING PROGRAM MANAGER:
Dianne Morrison
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2026


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 02/12/2026 04:36 PM - It Cannot Be Edited


Created By: Dianne Morrison On 02/12/2026 at 02:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WILLIAMS, SYMONE FCCH
FACILITY NUMBER: 483010826

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview the licensee did not comply with the section cited above. LS did not have records for children C1-C2, including LIC700, LIC995A, LIC627, LIC282, and LIC9150 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2026
Plan of Correction
1
2
3
4
Obtain all required forms from parents and file them into individual files and have on file for review. Please email all required forms to LPA: dianne.morrison@dss.ca.gov
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above in 2 out of 2 infant files. L1 did not have sleep logs for infants C1 and C2 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2026
Plan of Correction
1
2
3
4
Licensee stated she will begin logging sleep checks for infants C1 and C2, and submit one week's worth of sleep logs to LPA Morrison along with a signed and written statement of her understanding that the logs must be kept everyday the infant is in her care and must contain the infants Name, Date and Time of each 15 minute check. Email to LPA: dianne.morrison@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Melinda Mohr
NAME OF LICENSING PROGRAM MANAGER:
Dianne Morrison
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2026


LIC809 (FAS) - (06/04)
Page: 4 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WILLIAMS, SYMONE FCCH
FACILITY NUMBER: 483010826
VISIT DATE: 02/12/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Page 2

Items which could pose a danger to children (such as detergents, cleaning compounds, medications, etc.) were observed to be stored out of the reach of children. The Licensee stated there were no firearm(s) or other dangerous weapons stored on site. LPA observed a working smoke detector, carbon monoxide detector and a fire extinguisher that appeared to be charged and rated at least 2A10BC in the home. The licensee has conducted an emergency drill within the past six months; last drill was documented on February 12, 2026. LS did not have files for the two infant children present including proof of immunizations or LIC 700 for C1 and C2. Licensee was unable to provide a sleep log for infants C1 and C2. Facility and personnel files were reviewed.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for and removing any recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

On 02/04/2026, the Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility address. The Licensee confirmed that there are no Registered Sex Offenders living in the facility.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Melinda Mohr
NAME OF LICENSING PROGRAM ANALYST: Dianne Morrison
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026
LIC809 (FAS) - (06/04)
Page: 6 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WILLIAMS, SYMONE FCCH
FACILITY NUMBER: 483010826
VISIT DATE: 02/12/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Page 3

To improve the quality and value of the inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided.

A notice of site visit was given and must remain posted for 30 days.

Exit interview was conducted, and this report was reviewed with the licensee, Symone Williams.

NAME OF LICENSING PROGRAM MANAGER: Melinda Mohr
NAME OF LICENSING PROGRAM ANALYST: Dianne Morrison
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026
LIC809 (FAS) - (06/04)
Page: 7 of 7