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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 230111843
Report Date: 10/28/2022
Date Signed: 10/28/2022 04:53:34 PM


Document Has Been Signed on 10/28/2022 04:53 PM - 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: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: 17DATE:
10/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:51 PM
MET WITH:Crystal FloresTIME COMPLETED:
01:15 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
An inspection was conducted by Licensing Program Analyst ( LPA) Mary Trinh for the purpose of confirming the removal of an excluded individual "Natalie Mendez" . LPA Trinh met with the Site Supervisor, Crystal Flores who stated the individual 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 the facility and the excluded individual was not present. Based on evidence obtained during today's inspection, LPA Trinh 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 Trinh 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: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2022
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