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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 233009927
Report Date: 01/12/2023
Date Signed: 01/12/2023 12:42:38 PM

Document Has Been Signed on 01/12/2023 12:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:KISHBAUGH, AYLA FCCHFACILITY NUMBER:
233009927
ADMINISTRATOR:KISHBAUGH, AYLAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 813-0576
CITY:FORT BRAGGSTATE: CAZIP CODE:
95437
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
01/12/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Ayla KishbaughTIME COMPLETED:
01:00 PM
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
Licensing Program Analyst (LPA) Glenn Ouye met with licensee, Ayla Kishbaugh who is requesting to come off inactive status.

The applicant has decided to operate on a drop in basis at this point.

LPA inspection the interior and exterior of the home. The licensee has a spa on the rear deck with a lockable cover. LPA explained to the licensee that while the day care in open the cover and lock must be on the spa to remain in compliance.

Safe sleep regulations, the individual infant sleep plan and the sleep log were provided to and discussed with the licensee.

LPA will process the license back to active status effective January 12, 2023.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Glenn Ouye
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2023
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