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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483010121
Report Date: 09/09/2022
Date Signed: 09/09/2022 10:07:06 AM

Document Has Been Signed on 09/09/2022 10:07 AM - 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:HEAD START - COUCH INFANT/TODDLERFACILITY NUMBER:
483010121
ADMINISTRATOR:WINSTON, RHONDAFACILITY TYPE:
830
ADDRESS:579 COUCH STREETTELEPHONE:
(707) 252-8931
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 20TOTAL ENROLLED CHILDREN: 20CENSUS: 0DATE:
09/09/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Susan SmithTIME COMPLETED:
09:47 AM
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Licensing Program Analyst (LPA) Glenn Ouye met with Susan Smith to conduct a prelicensing inspection for this change of location application submitted on September 22. 2021. The prior location was from the Head Start - North Vallejo Community Center location.

This is a combination center that will have preschool age program and an infant/toddler program.

The infant license will utilize two rooms: rooms 1 and 2.

Room 1 will be used for infants up to 24 months of age.
Room 2 will be used for toddlers ages 18 to 36 months.

The rooms have sufficient square footage, toilets and sinks to support the capacity. There are age appropriate furniture, equipment and toys for the children in care. There are functioning smoke and carbon monoxide detectors. Each room has a fire extinguishers rated at least at 2A10BC. There are sufficient cribs for the infants and a refrigerator to store breast milk and formula for the infants.

The outdoor area also has sufficient square footage to support the capacity. The outdoor area is fully fenced. There are separate infant and toddler areas with shade structures for the children. The Program Director indicated that a wood fence will be built on the outside of the interior rod iron fence which will serve as a visual barrier between the children and the environment outside of the facility.

The facility agrees to complete the water lead testing within 6 months of licensure.

The facility is approved for licensure effective today, September 9, 2022..
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Glenn Ouye
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2022
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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