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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483010050
Report Date: 08/30/2022
Date Signed: 08/30/2022 07:15:12 PM

Document Has Been Signed on 08/30/2022 07:15 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 FCCHFACILITY NUMBER:
483010050
ADMINISTRATOR:PAYNE, JESSICAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 655-6210
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 14TOTAL ENROLLED CHILDREN: 21CENSUS: 6DATE:
08/30/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Licensee Jessica PayneTIME COMPLETED:
07:25 PM
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Licensing Program Analyst (LPA) Elpidia Hernandez Torres arrived to the facility to conduct a Plan of Correction (POC) visit to review children files, documents that are required to be posted, disaster drill log, infant safe sleep log and sleep plan which were previously cited on 08/16/2022.

LPA reviewed files for four children C1-C4, all children's files had required emergency information on file, infants had sleep log on file, and immunizations were transcribed on blue CDPH 286. Two children who were previously missing files have not returned since 08/16/2022. Disaster drill was conducted on 08/26/2022 with three children in attendance. Required documents to be posted have been posted.

LPA also provided Licensee with an amended report from 08/16/2022, pool was cited Immediate $500 Civil penalty for being accessible LPA cleared the POC through visit on 08/25/2022.

No deficiencies were cited during todays visit. Notice of site visit must be posted for 30 days.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2022
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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