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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009773
Report Date: 05/17/2024
Date Signed: 05/17/2024 01:28:29 PM

Document Has Been Signed on 05/17/2024 01:28 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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:PEREZ, EMILIO FCCHFACILITY NUMBER:
493009773
ADMINISTRATOR/
DIRECTOR:		EMILIO PEREZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 230-1631
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 14TOTAL ENROLLED CHILDREN: 13CENSUS: 10DATE:
05/17/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:10 PM
MET WITH:Emilio PerezTIME VISIT/
INSPECTION COMPLETED:
01:38 PM
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Licensing Program Analyst (LPA), Amy Strother conducted a Plan of Correction (POC) visit and met with Licensee, Emilio Perez (L1) for the purpose of following up on one Type B deficiency cited on 04/25/24. L1 was cited a Type B deficiency based on a review of records and L1’s statement that he did not have sleep logs as required for two infants (C1 & C2) in care. On 05/03/24 L1 emailed sleep logs for C1 & C2 to LPA Strother.

The purpose of today’s POC visit is to review files of infants in care to confirm that sleep logs are current and to clear the above Type B citation. Based on LPA’s review of two records for infants C1 & C2 in care during the inspection, L1 is in compliance with current sleep logs on file, clearing the deficiency.

The deficiency issued on 04/25/24 has been cleared and the Plan of Correction met.

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

Exit interview conducted and report reviewed with L1. 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. Appeal Rights were provided

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2024
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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