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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490105368
Report Date: 08/02/2024
Date Signed: 08/02/2024 09:55:53 AM

Document Has Been Signed on 08/02/2024 09:55 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 RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:LITTLE SHEPHERD LUTHERAN PRESCHOOLFACILITY NUMBER:
490105368
ADMINISTRATOR/
DIRECTOR:		NAUGLE, KIMBERLYFACILITY TYPE:
850
ADDRESS:220 STANLEY STREETTELEPHONE:
(707) 769-0462
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY: 70TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
08/02/2024
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:14 AM
MET WITH:Melissa BurgessTIME VISIT/
INSPECTION COMPLETED:
10:11 AM
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On 8/2/24, Licensing Program Analyst (LPA) Robert Maciel made a licensee initiated case management visit for the purpose of obtaining documents and signatures to complete a director change for the facility. LPA met with facility representative Melissa Burgess.

LPA obtained documents and signatures for the director packet of Melissa Burgess.

Exit interview and report was reviewed with facility representative Melissa Burgess. A notice of sight visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2024
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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