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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500740
Report Date: 10/21/2022
Date Signed: 04/03/2024 02:55:16 PM

Document Has Been Signed on 04/03/2024 02:55 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
SACRAMENTO S. CC RO, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:CANNON, ASIAFACILITY NUMBER:
394500740
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 3CENSUS: 0DATE:
10/21/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Asia CanonTIME COMPLETED:
01:00 PM
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This is an amended version of report originally signed on 10/20/22.
On Friday, October 20, 2022, Licensing Program Analysts (LPAs) Elvira Sierra and Stacey Williams met with Applicant, Asia Cannon for the purpose of a change of location. Applicant moved from previous address license #394500424 to current location. Home is a one story 3 bedrooms 2 bathrooms house. Facility hours of operation will be 24 hours a day Monday to Saturday. Licensee was advised never to exceed 24 hours of consecutive care.
LPA inspected all areas of the home for health and safety. Off-limit areas are; All bedrooms, garage, front yard and backyard. Applicant acknowledged that children may never enter these off-limit areas. Adult residents have criminal record clearances. LPA observed current CPR/First Aid certificate (expires 03/20/23). Parent's Rights, current Emergency Disaster Plan were observed posted. Safe toys and comfortable accommodations were observed. Applicant stated there are no weapons in the home. Home was observed having a 2A:10-BC fire extinguisher, a working telephone and smoke and carbon monoxide detectors. Cleaning compounds, and hazardous materials are inaccessible to children. There are no bodies of water in the home. The backyard is fenced for supervision. Applicant acknowledges children must be 100% supervised in unfenced areas or during water activities. Applicant rent the home and LPA Sierra received copy of Lease Agreement;

Licensee will be granted upon correction of the following:
-Landlord consent
-Barricade stairs in the home.

Exit interview was conducted and the report was provided and reviewed with Applicant, Asia Canon.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Elvira Sierra
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2022
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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