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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010083
Report Date: 06/20/2022
Date Signed: 06/20/2022 01:57:58 PM

Document Has Been Signed on 06/20/2022 01:57 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:ACHIEVERSFACILITY NUMBER:
493010083
ADMINISTRATOR:HEATHER PETERSFACILITY TYPE:
850
ADDRESS:573 SUMMERFIELD ROADTELEPHONE:
(707) 539-6232
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 90TOTAL ENROLLED CHILDREN: 90CENSUS: 24DATE:
06/20/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Heather Peters, Neeru VermaniTIME COMPLETED:
01:35 PM
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An unannounced case management inspection was conducted by Licensing Program Analyst Jennifer Velasco (LPA), who met with Director Heather Peters (D1) and Licensee Neeru Vermani (L1) to review staff response to the incident documented via Unusual Incident Report (UIR) on 05/24/2022. Per UIR, a wall-mounted fire extinguisher fell and went off, spreading fire-retardant powder in the entry hall and setting off the facility's alarm. No children were injured during this incident. LPA interviewed staff and children, toured the facility, and reviewed facility documents. Interviews and document reviews demonstrated no supervision or personal rights violations leading up to, during, or after the incident.

No title 22 regulations were cited today.
A Notice of Site Visit is to be posted for 30 days from today.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Jennifer Velasco
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2022
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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