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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480111584
Report Date: 06/14/2019
Date Signed: 06/14/2019 10:35:09 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:PREMYODHIN, SUPAB FCCHFACILITY NUMBER:
480111584
ADMINISTRATOR:PREMYODHIN, SUPABFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 426-0306
CITY:SUISUNSTATE: CAZIP CODE:
94585
CAPACITY:14CENSUS: 0DATE:
06/14/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Supad PremyodhinTIME COMPLETED:
10:35 AM
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Licensing Program Analyst Glenn Ouye arrived and met with licensee to discuss the inactive status. The licensee wishes to continue her inactive status has signed the LIC 9211. Her inactive status will be processed retroactively to 5/20/19 and will continue through 5/25/2020 unless the licensee notifies the department that she would like to go to active status.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Glenn OuyeTELEPHONE: (707) 588-5042
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2019
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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