<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483001191
Report Date: 09/10/2019
Date Signed: 09/10/2019 02:52:24 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:HEAD START - VIRGINIAFACILITY NUMBER:
483001191
ADMINISTRATOR:L.SMITH,J.EDWARDS,G.GARROTFACILITY TYPE:
850
ADDRESS:1328 VIRGINIATELEPHONE:
(707) 645-0634
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY:37CENSUS: 28DATE:
09/10/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:53 AM
MET WITH:Latissa SmithTIME COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Melchisedeck Augustin made an unannounced inspection at the facility to follow up on an unusual incident that occurred on 09/04/19, involving a neighbor who exhibited threatening behavior. The incident took place off site and did not impact the children in care. LPA met with Director Latissa Smith and LPA discussed the purpose of the inspection with the Director. At 11:19am, LPA conducted interviews with staff and Director, obtained a facility roster of the children in care; and obtained further information. The facility properly reported the incident to Community Care Licensing Division (CCLD) and no Title 22 deficiencies were issued during today’s inspection. This report was reviewed and discussed with the Director. Notice of Site Visit shall be posted for 30 days.



SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1