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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 173008755
Report Date: 10/30/2023
Date Signed: 10/30/2023 09:16:51 AM


Document Has Been Signed on 10/30/2023 09:16 AM - 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:BLOCKER, SHERRI FCCHFACILITY NUMBER:
173008755
ADMINISTRATOR:BLOCKER, SHERRIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 298-4474
CITY:LAKEPORTSTATE: CAZIP CODE:
95453
CAPACITY:14CENSUS: 0DATE:
10/30/2023
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Licensee, Sherri BlockerTIME COMPLETED:
09:20 AM
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On 10/30/2023, at 08:55AM, Licensing Program Analyst, Sebastian Phouthavong made an announced Case Management visit to the facility and met with Licensee, Sherri Blocker to verify operation at the facility, and to address the facility's forfeiture. Prior to visit, 10/27/2023, LPA confirmed the facility's closure with Licensee.

During the today visit, LPA toured the home inside and out. There was no evidence of operation and/or childcare being provided at the facility. Licensee stated she has not been operating since 10/2022. Licensee stated she will be moving and is no longer interested in operating a Family Child Care Home.

Licensee reviewed the requirements for License Exemption. LPA informed Licensee that a new application must be submitted to Community Care Licensing to become license once again. LPA received a statement of Closure as well.

The Completion of Closure have been met.

Exit interview conducted and report was reviewed with the Licensee, Sherri Blocker.

SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Sebastian PhouthavongTELEPHONE: 707-588-5056
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023
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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