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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
483010217
Report Date:
10/29/2024
Date Signed:
10/29/2024 12:48:15 PM
Document Has Been Signed on
10/29/2024 12:48 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:
SMITH, LATISSA FCCH
FACILITY NUMBER:
483010217
ADMINISTRATOR/
DIRECTOR:
SMITH, LATISSA
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
(707) 712-4839
CITY:
VALLEJO
STATE:
CA
ZIP CODE:
94589
CAPACITY:
14
TOTAL ENROLLED CHILDREN:
14
CENSUS:
4
DATE:
10/29/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:
Latissa Smith
TIME VISIT/
INSPECTION COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Glenn Ouye met with Latissa Smith to amend a complaint reporter originally dated September 25, 2025.
No deficiencies cited during todays visit.
SUPERVISORS NAME
:
Leslie Lepori
LICENSING EVALUATOR NAME
:
Glenn Ouye
LICENSING EVALUATOR SIGNATURE
:
DATE:
10/29/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/29/2024
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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