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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493006543
Report Date: 11/04/2019
Date Signed: 11/04/2019 02:00:41 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:NORTH BAY CHILDREN'S CENTER - SCHOOL-AGEFACILITY NUMBER:
493006543
ADMINISTRATOR:MARISA SCHEINBERGFACILITY TYPE:
840
ADDRESS:1001 CHERRY STREETTELEPHONE:
(707) 763-6222
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY:30CENSUS: 12DATE:
11/04/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Kerstin BandnerTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) J. Velasco made an unannounced visit to the facility and met with Administrator (D1). The purpose of the visit is to serve an Immediate Exclusion Order of a staff member which is effective today. The Order entitled “Order to Licensee/Facility of Immediate Exclusion From Facility” was served on the Licensee/Administrator and the Order entitled “Order to Individual of Immediate Exclusion From All Facilities” was served on the staff member (S1) at a separate location. Parties were provided an opportunity to read the contents of the Orders. The Licensee/Administrator understands the terms and conditions of the Order including the appeal rights. A copy of this report was provided to the Licensee/Administrator.LPA provided D1 with the Order, this report, and a Notice of Site Visit. The Notice of Site Visit is to be posted for thirty (30) days.


SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer VelascoTELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2019
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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