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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009441
Report Date: 08/13/2019
Date Signed: 08/13/2019 10:26:50 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:HEAD START-COOKFACILITY NUMBER:
493009441
ADMINISTRATOR:GROCOTT, LISAFACILITY TYPE:
850
ADDRESS:2480 SEBASTOPOL ROADTELEPHONE:
(707) 544-6911
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY:36CENSUS: 0DATE:
08/13/2019
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Lisa GrocottTIME COMPLETED:
10:45 AM
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A case management visit was made to the facility by Licensing Program Analyst (LPA) Amy Strother for the purpose of collecting an updated LIC200A application for a child care center license from Head Start Program Director, Lisa Grocott. The Program Director is requesting a capacity decrease of the preschool with toddler option license from it's current capacity of 36 to a decreased capacity of 28. The decrease is a result of the addition of a infant license to portable building #67. The preschool age children will remain in room #69 and the toddlers in room #68. LPA Strother met with Head Start Program Director, Lisa Grocott and obtained the updated LIC200A, an updated facility sketch, and a check for the decrease of capacity application in the amount of $25. LPA will issue an updated license to the facility once the changes have been updated in the system.
Notice of Site Visit shall be posted for 30 days from today's visit.

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

DATE: 08/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2019
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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