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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009502
Report Date: 12/21/2022
Date Signed: 12/21/2022 02:28:46 PM


Document Has Been Signed on 12/21/2022 02:28 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:JOHNSON, JENIQUE FCCHFACILITY NUMBER:
483009502
ADMINISTRATOR:JOHNSON, JENIQUEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 586-2907
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:14CENSUS: 0DATE:
12/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Licensee was unavailableTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA), Melchisedeck Augustin made an announced Case Management visit to verify operation status of the facility. On 08/12/22, the Licensee, Jenique Johnson (LS) sent a correspondence to notify the Department of her intent to vacate the facility, however; LS did not provide a date of when she planned to move. During today's visit, LS was unavailable, and the facility appeared to be vacated.

There were no furnishing or items inside the home and there was no indication that a childcare facility was being operated in the home, and LPA did not see any daycare children in the home. The facility license is forfeited in accordance with California Code of Regulations (CCR) 102383(a)(1), and the license will be closed effective, 12/21/2022. LS was unavailable to review this report.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2022
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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