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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483010122
Report Date: 03/11/2022
Date Signed: 03/11/2022 09:08:23 AM

Document Has Been Signed on 03/11/2022 09:08 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 - COUCHFACILITY NUMBER:
483010122
ADMINISTRATOR:WINSTON, RHONDAFACILITY TYPE:
850
ADDRESS:579 COUCH STREETTELEPHONE:
(707) 252-8931
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 72TOTAL ENROLLED CHILDREN: 72CENSUS: DATE:
03/11/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Susan SmithTIME COMPLETED:
09:00 AM
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Licensing Program Analysts (LPAs) Ouye and Augustin met with Program Director Susan Smith to conduct the outdoor capacity determination for the child care, infant and toddler programs for this combination center. The outdoor activity area is almost completed but still under construction.

LPA Ouye and Augustin will return to conduct the prelicensing inspection when the site construction is completed.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Glenn Ouye
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2022
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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