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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493000369
Report Date: 05/24/2019
Date Signed: 05/24/2019 12:37:19 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:R.L. STEVENS EXTENDED CHILD CAREFACILITY NUMBER:
493000369
ADMINISTRATOR:WILSON, DORISFACILITY TYPE:
840
ADDRESS:2345 GIFFEN AVENUETELEPHONE:
(707) 579-2627
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY:112CENSUS: 0DATE:
05/24/2019
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Jason RiggsTIME COMPLETED:
12:55 PM
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LPA Strother made an announced inspection and met with Executive Director of Extended Child Care, Jason Riggs for the purpose of adding two classrooms to the license for use over the summer months. Riggs has requested to add classroom #24 and #25 to the license and remain at a total capacity of 112. The following documents were obtained during today's inspection LIC999, facility sketches for both classrooms #24 and #25, an updated LIC200A application for a child care center license, and LIC9054 local fire inspection authority information were obtained. LPA Strother measured both classroom #24 and #25 and documented the measurements on form LIC9024 Capacity Worksheet. Based on measurements, the capacity limitations of room #24 and #25 together is 43 children. Riggs stated that the summer 2019 program plans to use classroom #1, #2, #24, #25, the multipurpose room (MPR) and the library, pending fire clearance for rooms #24 and #25.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2019
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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