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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480111584
Report Date: 01/21/2022
Date Signed: 01/21/2022 11:20:36 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: 5DATE:
01/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Licensee Supab PremyodhinTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Elpidia Hernandez Torres met with Licensee to conduct a visit for the purpose of going " Back-to- Active", or coming off of " In-Active" status. LPA reviewed LIC 126 Entrance checklist for Family child care homes. LPA provided Licensee with LIC 9040 Facility Roster, LIC 610 Emergency Disaster Plan, and LIC 9148 Earthquake preparedness. LPA reminded Licensee the forms that were required to be posted and toured the Day-care on limit areas. Day-care will be open Monday-Friday 06:00AM-06:00PM.

A notice of site visit was given and must remain posted for 30 days. There were no Title 22 deficiencies cited today.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Elpidia Hernandez TorresTELEPHONE: (707) 771-5568
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
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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