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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010145
Report Date: 05/01/2024
Date Signed: 05/01/2024 11:35:53 AM

Document Has Been Signed on 05/01/2024 11:35 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:NGUYEN, HOANG & MATTHEW FCCHFACILITY NUMBER:
493010145
ADMINISTRATOR/
DIRECTOR:		NGUYEN, HOANG & MATTHEWFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 303-6417
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 14TOTAL ENROLLED CHILDREN: 6CENSUS: 5DATE:
05/01/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:58 AM
MET WITH:Matthew and Hoang NguyenTIME VISIT/
INSPECTION COMPLETED:
11:39 AM
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A case management visit was made to the facility by Licensing Program Analyst (LPA) Y. Yang to provide technical assistance to the licensee regarding infant safe sleep regulations, infant sleep check logs, and adding an adult resident to the facility roster. During today's visit, the LPA obtained documents from the licensee to add adult A1 to the list of adults residing at the facility. There are currently three adults living in the home.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensees, Matthew and Hoang Nguyen. There were no Title 22 deficiencies cited during today's inspection.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Yang Yang
LICENSING EVALUATOR SIGNATURE: DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2024
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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