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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490111249
Report Date: 01/10/2024
Date Signed: 01/10/2024 10:54:10 AM

Document Has Been Signed on 01/10/2024 10:54 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 RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SAN MIGUEL EXTENDED CHILD CAREFACILITY NUMBER:
490111249
ADMINISTRATOR:JASON RIGGSFACILITY TYPE:
840
ADDRESS:5350 FAUGHT ROADTELEPHONE:
(707) 546-0667
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 128TOTAL ENROLLED CHILDREN: 128CENSUS: 0DATE:
01/10/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sonja KaluahineTIME COMPLETED:
11:00 AM
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A Case Management – Annual Continuation visit was made to the Extended Child Care main office located at 1745 Copperhill Pkwy Ste. #5 Santa Rosa, CA 95403 by Licensing Program Analyst (LPA),Sebastian Phouthavong. LPA met with facility representative, Laura Wasson.

During today’s visit LPA reviewed five staff files. All files contained complete records as required. At least one staff member, Site Supervisor, present during the Required – 1 Year inspection completed on 12/21/2023, possessed current pediatric CPR and First Aid certifications, Site Supervisor’s certificate expires 01/2024.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP).

An exit interview was conducted and the report was reviewed with facility representative, Laura Wasson.

There were no Title 22 deficiencies cited during today's file review.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2024
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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