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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009685
Report Date: 07/14/2022
Date Signed: 07/14/2022 11:48:09 AM

Document Has Been Signed on 07/14/2022 11:48 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:SIMONS, CAROLYN FCCHFACILITY NUMBER:
493009685
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
07/14/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Carolyn SimonsTIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Amy Strother received a call on 06/09/22 from Licensee Carolyn Simons (L1), stating that she will be closing her Family Child Care Home on 07/07/22. LPA Strother requested that L1 mail in her physical license with a written statement, stating that she wishes to terminate her license as of a specified date and will not be providing child care with signature and date. The physical license was received by the Santa Rosa Regional Office on 07/12/22, stating that the last day of care was 07/07/22. Today, a visit was made to L1’s home by LPA Strother to confirm closure.

At 11:35am LPA Strother met with Carolyn Simons in the home to confirm the facility closure. LPA did not observe any children in care during today's visit. Simons stated she understands that providing unlicensed child care is a violation of California Health and Safety Code Sections 1596.80 and 1597.54. Simons stated she can only be providing exempt care to her own family members children and the children of one family, if desired.

Simons stated that she understands that effective, 07/07/22 she is no longer licensed and can no longer provide licensed care to children in her home. If Simons wishes to provide licensed care in the future, she will need to reapply.

LPA Strother will process the closure with the effective closure date of July 07, 2022.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2022
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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