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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 173010140
Report Date: 04/22/2022
Date Signed: 04/22/2022 11:46:01 AM


Document Has Been Signed on 04/22/2022 11:46 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:HECKARD, JASMINE FCCHFACILITY NUMBER:
173010140
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: DATE:
04/22/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Jasmine HeckardTIME COMPLETED:
11:45 AM
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Licensing Program Analyst's (LPA) Glenn Ouye and Sebastian Phouthavong arrived and met with licensee Jasmine Heckard to conduct a capacity increase. The licensee is going from a small to a large FCCH. The approved fire inspection was received on 4/21/22.

The facility has functioning smoke and carbon monoxide detectors and a fully charged fire extinguisher rated at 2A10BC.

The capacity increase is approved effective today, April 22, 2022.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Glenn OuyeTELEPHONE: (707) 588-5042
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2022
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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