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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010010
Report Date: 10/11/2023
Date Signed: 10/11/2023 10:15:39 AM

Document Has Been Signed on 10/11/2023 10:15 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:ESCOBAR, VANESSA FCCHFACILITY NUMBER:
493010010
ADMINISTRATOR:ESCOBAR, VANESSAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 770-3527
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 14TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
10/11/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Vanessa EscobarTIME COMPLETED:
10:04 AM
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A follow up case management visit to the facility was made by Licensing Program Analysts (LPAs) Y. Yang and C. Castro. Previously, an unannounced annual inspection visit to the facility was made on 10/05/23. During this inspection visit, the LPA cited the licensee for an adult resident (adult A1) not having their criminal record clearance. As a result of this, a civil penalty was assessed. Due to technical issues, the LPA was unable to generate the LIC421BG form for the licensee. During today's follow up visit, the LPA provided the licensee with an LIC421BG form and obtained a signature on the form from the licensee.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee, Vanessa Escobar. There were no Title 22 deficiencies cited during today's inspection.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Yang Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2023
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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