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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493004901
Report Date: 10/15/2019
Date Signed: 10/15/2019 02:51:50 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:W. H. PEPPER PRESCHOOL INC.FACILITY NUMBER:
493004901
ADMINISTRATOR:WASIELEWSKI, CAROLYNFACILITY TYPE:
850
ADDRESS:627 F STREETTELEPHONE:
(707) 762-8151
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY:25CENSUS: 11DATE:
10/15/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Erica LewisTIME COMPLETED:
03:00 PM
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LPA Velasco made a Case Management visit to the facility because, due to software issues, LPA needed to get signatures from the facility director (D1) and print facility inspections reports.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer VelascoTELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2019
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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