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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009888
Report Date: 03/08/2023
Date Signed: 03/08/2023 04:46:23 PM

Document Has Been Signed on 03/08/2023 04:46 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:REED, KYWANNA FCCHFACILITY NUMBER:
483009888
ADMINISTRATOR:REED, KYWANNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 654-8563
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 14TOTAL ENROLLED CHILDREN: 18CENSUS: 10DATE:
03/08/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
04:04 PM
MET WITH:Erica Agnew - StaffTIME COMPLETED:
05:00 PM
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` Licensing Program Analyst (LPA), Melchisedeck Augustin conducted a Plan of Correction (POC) visit and met with the facility representative, Erica Agnew, for the purpose of following up on a type B deficiency that was cited. On 02/15/23, the facility was cited for operating out of ratio, when LPA observed one staff (S1) alone was providing care and supervision for nine children. Upon LPA's arrival at 4:04pm, there were eight children in the care of the facility representative, and moments later, another staff (S2) arrived with two additional children to provide additional support, and there was a total of ten children in the care of two staff. Based on LPA's observations, the facility is complying with the staffing ratio requirements. LPA cleared the deficiency, provided a POC clearance letter; consulted on and provided the facility representative with California of Regulations (CCR) 102416.5.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview conducted and report was reviewed with the facility representative, Erica Agnew. There were no violation(s) of the California Code of Regulations, Title 22 issued during this visit.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2023
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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