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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493001202
Report Date: 09/06/2023
Date Signed: 09/06/2023 03:38:28 PM


Document Has Been Signed on 09/06/2023 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 RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:BLACK, LISA FAMILY CHILD CARE HOMEFACILITY NUMBER:
493001202
ADMINISTRATOR:BLACK, LISAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 874-9104
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY:14CENSUS: 2DATE:
09/06/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Lisa BlackTIME COMPLETED:
03:45 PM
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Licensing Program Analysts (LPAs), Selena Mariani and Amy Strother conducted a follow up Plan of Correction (POC) visit and met Licensee Lisa Black (L1) for the purpose of following up on two Type B deficiencies that was cited on 08/03/23, with a due date of 09/1/23. On 08/03/23 L1 was cited based on she has not completed the Mandated Reporter Training and was missing children’s immunization records for C1-C3.

During today’s visit, L1 proved proof of Mandated Reporter training and current immunization records for C1-C3 clearing the above deficiencies. A letter of deficiency cleared for both Type B deficiencies and given to L1.

Report was reviewed with the Licensee, Lisa Black.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Selena MarianiTELEPHONE: (916) 605-8974
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2023
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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