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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480111584
Report Date: 08/21/2024
Date Signed: 08/21/2024 02:37:26 PM

Document Has Been Signed on 08/21/2024 02:37 PM - 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:PREMYODHIN, SUPAB FCCHFACILITY NUMBER:
480111584
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 1CENSUS: 0DATE:
08/21/2024
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Supab Premyodhin - LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
NARRATIVE
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Licensing Program Analyst (LPA), Melchisedeck Augustin made an unannounced Case Management visit and met with Licensee (LS), Supab Premyodhin. LPA’s initial intent was to conduct an Annual/Random inspection, however; upon arrival, LS expressed interest in forfeiting the facility license, due to personal reason(s). LS relinquished her original license with a written statement reflecting she was no longer interested in operating a childcare facility. According to LS, she only had child enrolled in care which LS picked up from school and dropped that child directly home, and LS claimed that the child never entered the facility; and LS expressed interest in only providing exempt care.

The facility fee was current and during the visit, LPA took a tour of the facility on limits areas and based on LPA’s observations; there were zero children present. LPA provided copies of California Code of Regulations (CCR) 102358, 102383, and Health and Safety Code 1596.858 and consulted with LS on license exemptions of California Code of Regulations (CCR) 102358 and 102383, which, indicated that the provider may provide care for her own children and for the children of one family. The facility license is forfeited in accordance with CCR 102383(a)(1), and the license will be closed effective, 08/21/2024. This report was discussed and reviewed with Licensee, Supab Premyodhin.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2024
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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