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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010083
Report Date: 09/01/2021
Date Signed: 09/01/2021 11:21:59 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:ACHIEVERSFACILITY NUMBER:
493010083
ADMINISTRATOR:KOHLI, DIVYAFACILITY TYPE:
850
ADDRESS:573 SUMMERFIELD ROADTELEPHONE:
(352) 871-2756
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY:90CENSUS: 27DATE:
09/01/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Divya Kohli and Neeru VermaniTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Glenn Ouye met with new licensees Divya Kohli and Neeru Vermani to conduct the final licensing visit. The new fire alarm has been installed and the approved fire inspection was received by the department on August 31, 2021. A copy of the approved fire clearance was given to the licensees.

LPA Ouye and the licensees confirmed and added all staff which require criminal record clearance and association to the Achievers facility.
LPA Ouye also provided the new licensee's with info regarding incidental medical services, staff to child ratio, unusual incident report requirements, child rosters requirements and required postings.

The facility is approved for licensure effective September 1, 2021.

SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Glenn OuyeTELEPHONE: (707) 588-5042
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
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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