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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493000369
Report Date: 06/07/2019
Date Signed: 06/07/2019 10:41:29 AM

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:
06/07/2019
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Jason RiggsTIME COMPLETED:
10:55 AM
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On 06/07/19 Licensing Program Analyst (LPA), Amy Strother made an unannounced visit to Extended Child Care office located at 1745 Copperhill Pkwy Ste #5, Santa Rosa, CA 95403 and met with Executive Director, Jason Riggs for the purpose of reviewing staff and children's files for R.L. Stevens Extended Child Care. LPA Strother conducted an annual random inspection of R.L. Stevens Extended Child Care on 05/31/19. Present during the inspection on 05/31/19 were 43 children, supervised by the director, 1 teacher, 1 assistant teacher and 1 substitute teacher. During today's file review, 2 staff files were reviewed, Staff 1 (S1) and Staff 2 (S2), at least one staff member that was during the inspection to the facility on 05/31/19 (S1) possessed current CPR and First Aid certification. S1 and S2 files contained documentation of education and training as required. Five children’s records, Child 1 - Child 5 (C1-C5) were reviewed at 10:00 a.m., and contained signed admission agreements and all of the required documents to be kept in children's records.

This report, was discussed with Executive Director, Jason Riggs. All licensing reports are public information and must be made available upon request for at least three years.

There were no Title 22 deficiencies cited during today's file review.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2019
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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