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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009106
Report Date: 05/03/2024
Date Signed: 05/03/2024 02:35:29 PM

Document Has Been Signed on 05/03/2024 02:35 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:HILL, RENAY FCCHFACILITY NUMBER:
493009106
ADMINISTRATOR/
DIRECTOR:		HILL, RENAYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 484-5278
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY: 14TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
05/03/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:14 PM
MET WITH:Renay HillTIME VISIT/
INSPECTION COMPLETED:
02:25 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
A case management visit was made to the facility by Licensing Program Analyst (LPA) Y. Yang to provide technical assistance and cover regulations pertaining to children's Incidental Medical Services (IMS). During the visit, the LPA provided the licensee with form LIC 9166 "Nebulizer Care Consent/Verification" and information regarding the Incidental Medical Service Plan of Operation.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee, Renay HIll. There were no Title 22 deficiencies cited during today's inspection.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Yang Yang
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2024
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 1