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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493008770
Report Date: 05/20/2024
Date Signed: 05/20/2024 04:47:13 PM

Document Has Been Signed on 05/20/2024 04:47 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:FERRONI, MIRIAN FCCHFACILITY NUMBER:
493008770
ADMINISTRATOR/
DIRECTOR:		FERRONI, MIRIANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 981-6473
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
05/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Mirian FerroniTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On 05/20/2024, Licensing Program Analyst (LPA), Leticia Rosales-Meza made an unannounced Case Management visit to follow up on Unusual Incident Report (UIR) that was submitted on 05/08/2023 from the Licensee, Mirian Ferroni. The incident was self reported by phone to Community Care Licensing (CCL) on 05/01/24, followed by a written Unusual Incident Report (UIR) received by CCL on 05/08/24, in compliance with the reporting requirements. LPA met with Licensee, Mirian Ferroni and spoke with her regarding the UIR in which a child sustained an injury.

During today's inspection, LPA toured the facility inside and out and observed 8 children being supervised by Licensee and 2 staff members. LPA conducted an interviews with the Licensee, Child 1 (C1), and made observations.

Exit interview conducted and report was reviewed with facility representative, Licensee, Mirian Ferroni.

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

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Leticia Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2024
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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