<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009685
Report Date: 02/24/2023
Date Signed: 02/24/2023 09:24:00 AM

Document Has Been Signed on 02/24/2023 09:24 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 & RICHARD FCCHFACILITY NUMBER:
493009685
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 3DATE:
02/24/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Carolyn SimonsTIME COMPLETED:
09:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Glenn Ouye met with licensee Carolyn Simons to conduct a capacity increase case management visit. The fire inspector conducted the fire inspection yesterday (2/23/23). The inspector told the licensee that a single action dead bold/door knob would need to be installed before the fire clearance could be approved. All other aspects of the home were cleared. The new door hardware will be installed in several days and the licensee will send photos of the installed hardware to the fire inspector as directed. The fire inspector said that he would then approve the fire clearance.

The home has functioning smoke and carbon monoxide detectors. The fire extinguisher is rated at least 2A10BC. The capacity a child ratio requirements were discussed with the licensee.

Upon receipt of the approved fire clearance, the capacity from a small FCCH to a large FCCH will be approved.

No citations during the visit.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Glenn Ouye
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1