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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493007344
Report Date: 10/23/2024
Date Signed: 10/23/2024 09:00:25 AM

Document Has Been Signed on 10/23/2024 09:00 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 RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:OVERSHINER, KIMBERLY FCCHFACILITY NUMBER:
493007344
ADMINISTRATOR/
DIRECTOR:		OVERSHINER, KIMBERLYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 538-5475
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 14TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
10/23/2024
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Kimberly OvershinerTIME VISIT/
INSPECTION COMPLETED:
09:09 AM
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Licensing Program Analyst (LPA) Robert Maciel made a case management visit to the facility for the purpose of reviewing documents. On 10/23/24, Licensee Kimberly Overshiner emailed LPA requesting assistance to review a LIC9182 Criminal Background Clearance Transfer Request before submitting it to the department.

At 8:40 AM LPA arrived at the facility and observed the Licensee supervising 5 children. LPA reviewed the LIC9182 with the Licensee who gave the completed form to LPA.

No deficiencies were cited during today's inspection. A notice of site visit was given and must remain posted for 30 days. Failure to do so shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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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