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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 230111843
Report Date: 09/10/2019
Date Signed: 09/11/2019 08:43:18 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:NCO HEAD START - NO. UKIAHFACILITY NUMBER:
230111843
ADMINISTRATOR:SANCHEZ, DIANAFACILITY TYPE:
850
ADDRESS:1100 N. BUSH ST. BLDG ATELEPHONE:
(707) 462-3403
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY:19CENSUS: 0DATE:
09/10/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:26 PM
MET WITH:Diana Sanchez, Site SupervisorTIME COMPLETED:
03:15 PM
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An inspection was conducted by Licensing Program Analyst ( LPA), M. Trinh for the purpose of confirming the removal of an excluded individual "Luisana Robledo" . LPA Trinh met with the Site Supervisor who stated the individual who never worked at the facility and is not at the facility. The Site Supervisor confirmed that she is aware that the individual is not permitted to be in the facility at any time when children are in care. LPA Trinh toured all the facility and the excluded individual was not present. Based on evidence obtained during today's inspection, LPA has verified the individual is not present or employed at the facility. The Site Supervisor understands and is aware that an immediate $500 Civil Penalty will be assessed for having any adults work without background clearance. LPA provided Confirmation of Removal LIC 300B to the Site Supervisor. This report was reviewed and discussed with the Site Supervisor.
Verification of removal is complete.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Mary TrinhTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2019
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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