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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 233009419
Report Date: 09/07/2023
Date Signed: 09/07/2023 02:33:59 PM


Document Has Been Signed on 09/07/2023 02:33 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:PITTMAN, JENNIFER FCCHFACILITY NUMBER:
233009419
ADMINISTRATOR:PITTMAN, JENNIFERFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 391-3403
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY:14CENSUS: 0DATE:
09/07/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Jennifer PittmanTIME COMPLETED:
02:40 PM
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A case management visit was made to the facility today by Licensing Program Analyst (LPA) Robert Maciel to conduct a confirmation of facility closure visit.

The facility's licensee, Jennifer Pittman, stated that she ceased operation of her facility on 09/01/23.

During today's case management visit, the LPA observed no children in care or any evidence of childcare being provided at this address. A tour of the home was provided to the LPA by the licensee. The LPA provided the licensee with a confirmation of facility closure receipt letter during this visit.

Confirmation of facility closure is complete.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert MacielTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023
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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