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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 283009779
Report Date: 06/04/2019
Date Signed: 06/04/2019 10:56:00 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:WAGONER, MELINDA FCCHFACILITY NUMBER:
283009779
ADMINISTRATOR:MELINDA WAGONERFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 255-4659
CITY:NAPASTATE: CAZIP CODE:
94559
CAPACITY:14CENSUS: 0DATE:
06/04/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Melinda WagonerTIME COMPLETED:
11:10 AM
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LPA Kevin O'Connell made an unannounced case management inspection
for the purpose of approval for front yard use.
The front yard is not fenced and wraps around the front and one side of the home. The Licensee understands that she and/ or her assistant will use direct visual supervision at all times when children are present and the front yard is being used for child care.

A notice of Site Visit is to be posted for 30 days.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Kevin O'ConnellTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2019
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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