<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 173007616
Report Date: 10/28/2022
Date Signed: 10/28/2022 12:34:57 PM


Document Has Been Signed on 10/28/2022 12:34 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:LEARNING HOUSE - P/S, THEFACILITY NUMBER:
173007616
ADMINISTRATOR:ANNA ROSE MONTANEZFACILITY TYPE:
850
ADDRESS:14840 BURNS VALLEY ROADTELEPHONE:
(707) 995-2076
CITY:CLEARLAKESTATE: CAZIP CODE:
95422
CAPACITY:65CENSUS: 36DATE:
10/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Anna Rose MontanezTIME COMPLETED:
12:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Sebastian Phouthaovong made an unannounced Case Management visit to follow up on an Unusual Incident Report (UIR) submitted to CCL on 10/27/2022. LPA met with Director, Anna Rose Montanez (D1). The UIR regarded a child misbehaving and created an environment for other at the facility.

During today's inspection, LPA toured the facility inside and out and observed 36 children being supervised by 10 staff members. LPA conducted interviews with the Director and one staff member, reviewed facility documents and request documents.

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.

There were no Title 22 deficiencies cited during today's inspection.

Exit interview conducted and report was reviewed with facility representative, Anna Rose Montanez.

SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Sebastian PhouthavongTELEPHONE: 707-588-5056
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1