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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493000369
Report Date: 09/08/2022
Date Signed: 09/08/2022 05:52:38 PM

Document Has Been Signed on 09/08/2022 05:52 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:R.L. STEVENS EXTENDED CHILD CAREFACILITY NUMBER:
493000369
ADMINISTRATOR:JASON RIGGSFACILITY TYPE:
840
ADDRESS:2345 GIFFEN AVENUETELEPHONE:
(707) 579-6267
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 112TOTAL ENROLLED CHILDREN: 112CENSUS: 24DATE:
09/08/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
05:45 PM
MET WITH:Michelle DominguezTIME COMPLETED:
06:00 PM
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An initial required one year inspection was made to the facility by Licensing Program Analyst (LPA), Amy Strother on 09/08/22. The purpose of today’s visit is to conduct an Annual Continuation visit. During the visit on 09/08/22, Facility Representative and Director, Michelle Dominguez (D1) stated that all complete staff and children’s files are stored off site at the Extended Child Care main office. On 09/08/22 Licensing Program Analyst (LPA), Amy Strother made an unannounced visit to Extended Child Care office located at 1745 Copperhill Pkwy Ste #5, Santa Rosa, CA 95403 to review files. Based on record review of ten children’s records, Child 1 – Child 10 (C1-C10) and 3 staff files, D1, Staff 1 and Staff 2, the records are complete, containing all required documents.

During today’s Annual Continuation visit, LPA met with Director, Michelle Dominguez (D1).

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

There were no Title 22 deficiencies cited during today's inspection.

Exit interview conducted and report was reviewed with Facility Representative Michelle Dominguez.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2022
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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