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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 233007705
Report Date: 08/18/2023
Date Signed: 08/18/2023 02:26:56 PM


Document Has Been Signed on 08/18/2023 02:26 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:REYNOSO/PALMERIN FAMILY CHILD CARE HOMEFACILITY NUMBER:
233007705
ADMINISTRATOR:REYNOSO, CLAUDIA & PALMERIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 463-8468
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY:14CENSUS: 9DATE:
08/18/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Claudia Reynoso and Osvaldo PalmerinTIME COMPLETED:
02:45 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
Licensing Program Analyst (LPA), Leticia Rosales conducted an unannounced inspection at the facility and met with Licensees Claudia Reynoso and Osvaldo Palmerin. The purpose of the inspection is to serve the Immediate Exclusion Order of Adult 1 (A1), which is effective today, 8/18/23. The Order entitled Order to Licensee/Facility of Immediate Exclusion From Facility was served to Licensees Claudia Reynoso and Osvaldo Palmerin and the Order entitled Order to Individual for Immediate Exclusion From All Facilities was served to A1. LPA Rosales reviewed the contents of the Orders with licensees Claudia Reynoso and Osvaldo Palmerin and A1, who understand the terms and conditions of the Order including the appeal rights that were provided. LPA Rosales informed Licensees Claudia Reynoso and Osvaldo Palmerin to provide a copy of the Family Child Care Home (FCCH) Addendum to Notification of Parents’ Rights form LIC 995B form, regarding Removal/Exclusion dated 8/18/23, to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians. The completed LIC 995B form must be completed and signed by each parent/guardian and placed in each child's file for verification. LPA Rosales provided Licensees Claudia Reynoso and Osvaldo Palmerin with a copy of the LIC 995B form. Exit interview conducted, and report was reviewed with Licensees Claudia Reynoso and Osvaldo Palmerin.

Notice of Site Visit. Notice of Site Visit must be posted for thirty (30) days.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Leticia RosalesTELEPHONE: (707) 588-5061
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2023
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