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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 173007616
Report Date: 09/11/2023
Date Signed: 09/11/2023 02:11:08 PM


Document Has Been Signed on 09/11/2023 02:11 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: 33DATE:
09/11/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Anna Rose MontanezTIME COMPLETED:
02:20 PM
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An unannounced case management inspection was conducted by Licensing Program Analyst (LPA) Sebastian Phouthavong for the purpose of RSO notification and to verify if an individual is associated with the facility. LPA is also conducted a visit in response to an Unusual Incident Report submitted on 09/08/2023, involving a child’s behavior. LPA met with Site Supervisor; Anna Rose Montanez discussed the purpose of the inspection. LPA toured the entire facility, and the individual was not present.

During today's inspection, LPA observed 33 children being supervised by 8 staff members. LPA conducted interviews with the Site Supervisor and 2 staff members regarding the UIR. On the topic of the RSO notification, Site Supervisor stated the facility was notified RSO roughly last month about the individual and the person has only association with the owners of the center but has never worked or been present at the center, and does not reside in the area. Staff statement indicates that the individual has never been seen at the center, collaborating with the Site Supervisor’s statement.

Based on evidence obtained during today's visit, LPA has verified that the individual is not present, employed, or residing at the facility. The Director understands and is aware that an immediate $500 Civil Penalty will be assessed for having any adults work or live in the facility without background clearance. Verification of removal is complete.

Exit interview conducted and report was reviewed with the Site Supervisor, Anna Rose Montanez.

Notice of Site Visit shall be posted for 30 days from today's inspection.



There were no Title 22 deficiency cited during today's inspection.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Sebastian PhouthavongTELEPHONE: 707-588-5056
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2023
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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