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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010205
Report Date: 06/09/2023
Date Signed: 06/09/2023 02:23:22 PM

Document Has Been Signed on 06/09/2023 02:23 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SANCHEZ, PERLA FCCHFACILITY NUMBER:
493010205
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
06/09/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Licensee, Perla SanchezTIME COMPLETED:
02:35 PM
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On 06/09/2023, Licensing Program Analyst (LPA),Sebastian Phouthaovong made an unannounced Case Management visit to follow up on Unusual Incident Report (UIR) that was submitted on 06/06/2023 from the Licensee, Perla Sanchez. LPA met with Licensee, Perla Sanchez, and spoke with her the regarding the UIR.

During today's inspection, LPA toured the facility inside and out and observed 6 children being supervised by 2 staff members. LPA conducted interviews with the Licensee and one staff member and received documents. LPA reviewed reporting requirements that include notifying the Department by telephone or fax within the Department's next working day and written report within seven days.

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.

Exit interview conducted and report was reviewed with facility representative, Licensee, Perla Sanchez.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2023
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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