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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
483010050
Report Date:
07/18/2024
Date Signed:
07/18/2024 02:45:10 PM
Document Has Been Signed on
07/18/2024 02:45 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:
PAYNE, JESSICA FCCH
FACILITY NUMBER:
483010050
ADMINISTRATOR/
DIRECTOR:
PAYNE, JESSICA
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
(707) 655-6210
CITY:
FAIRFIELD
STATE:
CA
ZIP CODE:
94533
CAPACITY:
14
TOTAL ENROLLED CHILDREN:
21
CENSUS:
13
DATE:
07/18/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
02:25 PM
MET WITH:
Licensee Jessica Payne
TIME VISIT/
INSPECTION COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Elpidia Hernandez Torres arrived to the family child care home on 07/18/24 to read and collect signature on amended complaint report. Complaint report was originally issued on 07/12/2024 with unsubstantiated findings. The amended report kept the same unsubstantiated findings.
Licensee received a copy of the amended complaint report. No deficiencies were issued during today's visit.
SUPERVISORS NAME
:
Leslie Lepori
LICENSING EVALUATOR NAME
:
Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE
:
DATE:
07/18/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/18/2024
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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