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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 173002029
Report Date: 04/14/2023
Date Signed: 04/14/2023 04:37:58 PM


Document Has Been Signed on 04/14/2023 04:37 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:CABREROS, CATHY FAMILY CHILD CARE HOMEFACILITY NUMBER:
173002029
ADMINISTRATOR:CABREROS, CATHYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 994-9146
CITY:CLEARLAKESTATE: CAZIP CODE:
95422
CAPACITY:14CENSUS: 0DATE:
04/14/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:09 PM
MET WITH:TIME COMPLETED:
12:20 PM
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On 03/21/2023 at 12:09AM, Licensing Program Analyst, Sebastian Phouthavong made an unannounced Case Management visit to the facility to verify operation at the facility, and to address the facility's forfeiture. Prior to visit, Licensee, Cathy Cabreros received three notices of annual fees exceeding due date. LPA also received word that from individual that the facility was not providing day care as of today.

During the visit, LPA toured the home’s yard and observed nobody at the home.. LPA observed no evidence of operation and/or childcare being provided at the facility. LPA will follow up and attempt to conduct Licensee to confirm closure and/or If annual fees are not completed, LPA will continue with the facility's forfeiture.

Facility Representative Signature not available at this time.

SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Sebastian PhouthavongTELEPHONE: 707-588-5056
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2023
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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