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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483010644
Report Date: 11/14/2024
Date Signed: 11/14/2024 10:38:25 AM

Document Has Been Signed on 11/14/2024 10:38 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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ROMERO BALDIBIEZO, MERZI FCCHFACILITY NUMBER:
483010644
ADMINISTRATOR/
DIRECTOR:		ROMERO BALDIBIEZO, MERZIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 286-2612
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 14TOTAL ENROLLED CHILDREN: 10CENSUS: 0DATE:
11/14/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Merzi Romero BaldibiezoTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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A subsequent pre-licensing inspection was conducted today by Licensing Program Analyst (LPA), Cindy Castro for the purpose of verifying that items listed on prior pre-licensing visit dated 07/26/24 were repaired. During today's visit LPA inspected indoor and outdoors of the home. The floor and yard plans were verified. The following items were repaired:

1. Gate was placed on hallway to prevent access to wall heater and applicant stated that it will not be used.
2. Beauty products in bathroom cabinet under sink have a child safety lock.
3. Child safety gate was placed in the living room area to make inaccessible.
4. Gates were placed on both sides of home that is used for storage.
5. Key lock was placed on garage door.

Exit interview conducted and report was reviewed with the applicant, Merzi Romero Baldibiezo. This small FCCH application is approved for licensure effective 11/14/24.
SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Cindy Castro
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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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