<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493004071
Report Date: 11/20/2024
Date Signed: 11/21/2024 08:41:56 AM

Document Has Been Signed on 11/21/2024 08:41 AM - 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:DI GIUSEPPI, CAROLYNN FCCHFACILITY NUMBER:
493004071
ADMINISTRATOR/
DIRECTOR:		DI GIUSEPPI, CAROLYNFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 769-7921
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 10DATE:
11/20/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:58 AM
MET WITH:Carolynn Di GiuseppiTIME VISIT/
INSPECTION COMPLETED:
11:14 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
A case management visit was made to the facility by Licensing Program Analyst (LPA) Y. Yang. During today's visit, the LPA provided technical assistance to the licensee and provided information to the licensee regarding Title 22 regulations and information regarding the process of adding a co licensee to her license. The licensee stated that adult A1, an existing employee at this facility, will be moving into this facility effective 12/01/24. The licensee is requesting to add A1 as a co licensee on her license. The LPA obtained a signed LIC279, a valid TB test from A1, and a current pediatric first aid/CPR certificate. The licensee shall submit an FCCH orientation certificate and an EMSA approved preventative health and safety certificate for A1.

The exit interview has been conducted and this report has been reviewed with the licensee, Carolynn Di Giuseppi. There were no Title 22 deficiencies cited during today's visit. Notice of Site Visit shall be posted for 30 days.
Megan AvilesTELEPHONE: (530) -89-5033
Yang YangTELEPHONE: 707-588-5026
DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1