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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480110778
Report Date: 05/08/2023
Date Signed: 05/08/2023 11:25:53 AM


Document Has Been Signed on 05/08/2023 11:25 AM - 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:FAIRFIELD MONTESSORIFACILITY NUMBER:
480110778
ADMINISTRATOR:KRYSTEK & BAILEYFACILITY TYPE:
850
ADDRESS:1101 UTAH STREETTELEPHONE:
(707) 427-1442
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:30CENSUS: DATE:
05/08/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Lorraine KrysteckTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Glenn Ouye met with owner, Lorraine Krysteck to conduct a capacity determination as the facility is in the process of changing ownership.

LPA measured the interior and exterior square footage to confirm capacity and consulted with prospective owner and current owner.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Glenn OuyeTELEPHONE: (707) 588-5042
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2023
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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