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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010320
Report Date: 03/18/2025
Date Signed: 03/18/2025 04:20:38 PM

Document Has Been Signed on 03/18/2025 04:20 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 CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:CONTRERAS, KATY FCCHFACILITY NUMBER:
493010320
ADMINISTRATOR/
DIRECTOR:
CONTRERAS, KATYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 497-6695
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 14TOTAL ENROLLED CHILDREN: 4CENSUS: 5DATE:
03/18/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:17 PM
MET WITH:Katy ContrerasTIME VISIT/
INSPECTION COMPLETED:
03:48 PM
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An unannounced case management visit was made to the facility by Licensing Program Analyst (LPA) Y. Yang in response to a self-reported incident involving child C1 that occurred at the facility on 03/04/25. During today’s visit, the LPA met with the licensee, Katy Contreras to discuss the incident and obtain additional information. It was reported by the licensee that during lunch time on 03/04/25, child C1, an infant, was served a store bought English muffin that contained honey as an ingredient. The licensee reported that C1 has not previously consumed honey before but is known to have other food allergies and/or sensitivities. The licensee stated that C1 did not present any allergy symptoms and is not known to be allergic to honey. The licensee stated that out of an abundance of caution, she notified the child's authorized representative who consulted with C1's pediatrician. The licensee stated that C1's pediatrician stated that due to the small amount of honey consumed by C1, the risk of any adverse reaction was minimal.

During today's case management visit, the LPA provided technical assistance to the licensee regarding the use of incidental medical services (IMS) and the facility's allergy policies. The licensee stated that as a result of this incident, she has updated her facility policy and now requires authorized representatives of children in care to sign off on individual ingredients and food items before they are served at her facility.

This incident was reported to Community Care Licensing as required per regulations. There were no Title 22 deficiencies cited during today’s inspection visit. A notice of site visit was given and must remain posted for 30 days. This report was read and reviewed with the licensee, Katy Contreras.

SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Yang Yang
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2025
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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