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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483008971
Report Date: 09/10/2019
Date Signed: 09/10/2019 01:27:44 PM

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:CURTIS, LATASHA FCCHFACILITY NUMBER:
483008971
ADMINISTRATOR:CURTIS, LATASHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 421-8106
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY:14CENSUS: 6DATE:
09/10/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Latasha CurtisTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Glenn Ouye arrived and met with licensee Latasha Curtis. LPA arrived to meet with licensee regarding the payment of the annual fee in the amount of $210.00 which is outstanding.

During the visit the licensee paid the annual fee online and printed out a copy of the proof of payment.

No deficiencies cited during the visit.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Glenn OuyeTELEPHONE: (707) 588-5042
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)
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