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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 173008755
Report Date: 05/31/2019
Date Signed: 05/31/2019 08:37:03 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:BLOCKER, SHERRI FCCHFACILITY NUMBER:
173008755
ADMINISTRATOR:BLOCKER, SHERRIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 413-3106
CITY:LAKEPORTSTATE: CAZIP CODE:
95453
CAPACITY:14CENSUS: 9DATE:
05/31/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
07:45 AM
MET WITH:Sherri BlockerTIME COMPLETED:
08:50 AM
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Licensing Program Analyst (LPA) Chris Arnhold arrived to this facility unannounced to conduct a case management visit in connection to an exemption denial letter dated May 28, 2019. LPA met with Licensee Sherri Blocker and toured the facility. 9 children were in care supervised by the Licensee and an assistant. LPA and Licensee discussed the reasons for the denial and reviewed the appeal process. LPA inspected the facility and observed S1 was not present at the facility. Confirmation of removal documentation was reviewed with Licensee and LPA received signed confirmation paperwork.

Based on the evidence obtained during today’s visit, the LPA has verified the individual is not present, employed or residing at the facility. LPA has advised the licensee to disassociate the individual from their roster and submit an updated LIC 500.

Verification of removal is complete.

No deficiencies were observed and no citations issued during today's visit.

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

SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5056
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2019
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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