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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490170204
Report Date: 05/21/2024
Date Signed: 05/21/2024 11:09:45 AM

Document Has Been Signed on 05/21/2024 11:09 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:CLARK, CHARLOTTE AND CYNTHIA FCCHFACILITY NUMBER:
490170204
ADMINISTRATOR/
DIRECTOR:		CLARK, CHARLOTTEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 763-3683
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 14TOTAL ENROLLED CHILDREN: 13CENSUS: 3DATE:
05/21/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:46 AM
MET WITH:Cynthia "Cindy" ClarkTIME VISIT/
INSPECTION COMPLETED:
10:57 AM
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A case management visit was made to the facility by Licensing Program Analyst (LPA) Y. Yang. During today's visit, the LPA provided technical assistance to the licensee and provided information to the licensee regarding Title 22 regulations, infant safe sleep regulations, and best practice recommendations.

The exit interview has been conducted and this report has been reviewed with the licensee, Cindy Clark. There were no Title 22 deficiencies cited during today's visit. Notice of Site Visit shall be posted for 30 days.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Yang Yang
LICENSING EVALUATOR SIGNATURE: DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2024
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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