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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009674
Report Date: 12/09/2022
Date Signed: 12/09/2022 10:48:03 AM

Document Has Been Signed on 12/09/2022 10:48 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:MULDER, TONYA FCCHFACILITY NUMBER:
493009674
ADMINISTRATOR:MULDER, TONYAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 857-6563
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY: 14TOTAL ENROLLED CHILDREN: 10CENSUS: 1DATE:
12/09/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Tonya MulderTIME COMPLETED:
10:55 AM
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On 12/09/22 Licensing Program Analyst (LPA) Amy Strother conducted an unannounced Plan of Correction (POC) visit for the purpose of following up on deficiencies that were cited on 11/30/22, where the Licensee was operating over capacity, poisons were not locked, the facility did not have the size fire extinguisher (2A10BC) that meets the requirements and three children C1, C4 and C5 did not have immunization records on file. During today's inspection LPA met with License, Tonya Mulder (L1). L1 greeted LPA at the door stating that she is closed today due to a personal appointment and only has her grandchild present. LPA did not observe any other children in care. LPA observed a 2A10BC fire extinguisher present in the kitchen, poisons locked in laundry room with key locked door knob, and complete immunization records for C1, C4 and C5 were reviewed. LPA cleared the Type A deficiencies and Type B deficiencies dated 11/30/22. LPA Strother issued POC clearance letters to the Licensee.

This report was reviewed and discussed with the Licensee. All licensing reports are public information and must be made available upon request for at least 3 years.

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

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.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2022
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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