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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009999
Report Date: 06/24/2026
Date Signed: 06/24/2026 01:41:03 PM

Document Has Been Signed on 06/24/2026 01:41 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:CUEVAS, DIANA FCCHFACILITY NUMBER:
493009999
ADMINISTRATOR/
DIRECTOR:		CUEVAS, DIANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 774-2318
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 14TOTAL ENROLLED CHILDREN: 17CENSUS: 9DATE:
06/24/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:24 AM
MET WITH:Diana Cuevas - LicenseeTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA), Ivet Zamora Perez and Licensing Program Manager (LPM), Melchisedeck Augustin made an unannounced Case Management visit and met with Licensee, Diana Cuevas, for the purpose of delivering an amended complaint investigation report (LIC 9099/C/D). During the visit, there were nine children in care with Licensee and one staff (S1). LPA reviewed 17 children's (C4-C20) records to verify completeness of the Family Child Care Home Addendum to Notification Of Parent’ Rights- Regarding Removal/Exclusion (LIC 995B). Based on records reviewed, C10 and C18-C20's files were either missing the LIC 995B or the form did not contain the child's authorized representative's signature. According to the Licensee' statement, C10 and C19 have been on vacation for appoximately three weeks and just returned today 6/24/26. C18 had not attended care for more than one month and C20 had not been in care since 2/2026. LPA consulted with the Cuevas about the requirement to notify all parents of an excluded individual, and Cuevas acknowledged the requirements, and stated she would obtain the children's authorized representative's signature the next time the parent's either dropped off or picked up their child from care. Additionally, LPA reviewed record for S1 which revealed that S1 was missing proof of immunity against Pertussis; as well as evidence of negative TB clearance.

There following California Code of Regulations (Title 22) and/or Health and Safety Code were cited during today’s visit, on the attached LIC 809-D. Notice of Site Visit shall be posted for 30 days, and failure to comply with posting requirements shall result in a Civil Penalty of $100. Appeal Rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Ivet Zamora Perez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/24/2026 01:41 PM - It Cannot Be Edited


Created By: Ivet Zamora Perez On 06/24/2026 at 11:28 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CUEVAS, DIANA FCCH
FACILITY NUMBER: 493009999

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/08/2026
Section Cited
HSC
1597.622(a)(1)

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Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
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Licensee stated that S1 would request required immunization record from her medical doctor and Licensee intends to submit copy of S1's record to the department by 7/8/26, via email or fax.

Email: Ivet.perez@dss.ca.gov.
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This requirement was not met as evidenced by: based LPAs review of staff (S1) records. This revealed that S1 was missing proof of immunity against Pertussis. This poses/pose a potential health, safety, and/or personal rights risk to the children in care.
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Licensee stated that S1 would obtain her evidence of a negative TB clearance from her medical provider. Licensee intends to submit evidence of S1s clearance to the department by 7/8/26, via emai or fax.

Email: Ivet.perez@dss.ca.gov.
Type B
07/08/2026
Section Cited
CCR102369(b)(9)

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Evidence of a current tuberculosis clearance, not more than one year prior to or seven days after initial presence in the home, for any adult in the home during the time that children are under care.

This requirement was not met as evidenced
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by: Based on LPAs file review of staff (S1) record which revealed that S1 was missing evidence of negative TB clearance.This poses/pose a potential health, safety, and/or personal rights risk to the children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Melchisedeck Augustin
NAME OF LICENSING PROGRAM MANAGER:
Ivet Zamora Perez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2026


LIC809 (FAS) - (06/04)
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