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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483003054
Report Date: 01/08/2024
Date Signed: 01/08/2024 10:59:05 AM


Document Has Been Signed on 01/08/2024 10:59 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:STOVALL, CINDY FAMILY CHILD CARE HOMEFACILITY NUMBER:
483003054
ADMINISTRATOR:STOVALL, CINDYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 448-8775
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:14CENSUS: 7DATE:
01/08/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Cindy Stovall - LicenseeTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA), Melchisedeck Augustin made an unannounced Plan of Correction (POC) visit to follow up on outstanding POCs and met with Licensee (LS), Cindy Stovall. On 10/13/23, the facility was cited two type B deficiencies because LS did not furnish a record for S2, and LS, S1 & S2 were missing required staff Immunization Records (IR). During today's visit, LPA observed LS and S1 providing care and supervising for seven children in the converted garage. LPA reviewed three staff (LS, S1 & S2) at 9:58am which revealed the records were complete. LPA cleared the deficiencies and provided LS with copies of the Letters of Deficiencies Citations Cleared.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview conducted and report was reviewed with the licensee, Cindy Stovall. The was/were not violation(s) of California Code of Regulations, Title 22, Division 12, cited during today's visit.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2024
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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