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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490110022
Report Date: 02/27/2025
Date Signed: 02/27/2025 03:38:24 PM

Document Has Been Signed on 02/27/2025 03:38 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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:A SPECIAL PLACEFACILITY NUMBER:
490110022
ADMINISTRATOR/
DIRECTOR:		AMY DEJUNGFACILITY TYPE:
850
ADDRESS:1128 EDWARDS AVENUETELEPHONE:
(707) 523-2337
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 30TOTAL ENROLLED CHILDREN: 25CENSUS: 20DATE:
02/27/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Amy DejungTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Amy Strother made an unannounced case management visit to the facility after receiving an Unusual Incident Report (UIR) on 02/10/25, regarding a possible violation of children’s personal rights. LPA met with Facility Representative, Site Supervisor, Amy Dejung (D1).

During today’s visit, 20 students were being supervised by 4 teachers and the site supervisor, operating within the licensed capacity and ratio requirements. LPA interviewed D1, Staff 1-3 (S1-S3) and two children (C1 & C2).

Based on interviews conducted, there was not a preponderance of evidence to prove that an alleged violation of personal right occurred.

This report was reviewed and discussed with Site Supervisor, Amy Dejung. Appeal Rights were provided.

Notice of Site Visit shall be posted for 30 days from today's visit. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2025
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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