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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
283009460
Report Date:
07/01/2022
Date Signed:
07/01/2022 03:51:51 PM
Document Has Been Signed on
07/01/2022 03:51 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:
BROWN, HEIDI & KEVIN FCCH
FACILITY NUMBER:
283009460
ADMINISTRATOR:
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
CITY:
STATE:
ZIP CODE:
CAPACITY:
0
CENSUS:
1
DATE:
07/01/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
09:30 AM
MET WITH:
Jessica California, resident
TIME COMPLETED:
09:45 AM
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LPA made a Case Management inspection to follow up the closure of this facility as the Licensee stated that they moved out of state.
LPA confirmed that there was no child care going on at this home.
There was one young child who was the son of the resident.
SUPERVISOR'S NAME:
Leslie Lepori
TELEPHONE:
(707) 588-5060
LICENSING EVALUATOR NAME:
Kevin O'Connell
TELEPHONE:
(707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE:
07/01/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/01/2022
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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