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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214200048
Report Date: 01/07/2020
Date Signed: 01/08/2020 08:21:21 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:PAULSEN, NICOLEFACILITY NUMBER:
214200048
ADMINISTRATOR:PAULSEN, NICOLEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 302-4443
CITY:MILL VALLEYSTATE: CAZIP CODE:
94941
CAPACITY:14CENSUS: 12DATE:
01/07/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:56 PM
MET WITH:Nicole PaulsenTIME COMPLETED:
03:33 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
A case management inspection visit was made to the facility by Licensing Program Analyst (LPA) Y. Yang at the request of the licensee to provide Title 22 consultation and clear an outstanding deficiency cited on 11/13/15. This facility shares an outdoor play space with facility #214005300.

During today's case management visit, there were 12 children being supervised by the licensee and two assistants. This report and the Effects of Lead Exposure brochure were reviewed and discussed with the licensee.

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

There were no Title 22 deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang YangTELEPHONE: (707) 588-5015
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2020
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