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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304310878
Report Date: 09/18/2019
Date Signed: 09/18/2019 09:19:08 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:DAVIS-HENDERSON, ANNASTASIAFACILITY NUMBER:
304310878
ADMINISTRATOR:DAVIS-HENDERSON,ANNASTASIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 510-4663
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:14CENSUS: 9DATE:
09/18/2019
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Annastasia Davis-Henderson TIME COMPLETED:
09:30 AM
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Plan of correction visit to check deficiency cited on 09/09/19 was made this day by Licensing Program Analyst (LPA)Connolly. Present was licensee, assistant Kelley Metoyer, as well as nine children four of whom infants. Licensee is operating within the capacity and ratio of the large family child care home license.

The last Notice of Site Visit was posted along with the report. Parent verification of receipt was in each child’s file.

An exit interview was completed. The report was reviewed and discussed. Appeal Rights were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the licensing office within 15 business days.

No deficiencies observed today.

Notice of Site Visit was posted.

The facility representative was informed that the 'Notice of Site Visit' must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.00. The 'Notice of Site Visit' must be posted on or adjacent to the door.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Gesine ConnollyTELEPHONE: (714) 293-9314
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2019
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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