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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010160
Report Date: 09/21/2023
Date Signed: 09/21/2023 11:01:17 AM

Document Has Been Signed on 09/21/2023 11:01 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:JOHNSON, TIFFANY FAMILY CHILD CARE HOMEFACILITY NUMBER:
493010160
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 6CENSUS: 4DATE:
09/21/2023
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Tiffany JohnsonTIME COMPLETED:
09:40 AM
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On 09/21/2023, Licensing Program Analyst, Sebastian Phouthavong has conducted Case Management Visit regarding Licensee requesting for an increase of capacity to the daycare. Today, LPA met with Licensee, Tiffany Johnson. Prior to visit, Licensee received a Fire Safely Inspection conducted by the local fire department and LPA received an approved STD 850 for an increase of capacity to 12 daycare children on 09/19/2023.

During the inspection the home was toured inside and outside. The licensee was supervising 4 children and operating within the licensed capacity and ratio requirements. The facility’s operating hours are Monday – Friday 7:30am - 5:00pm. The floor plan submitted by the licensee was reviewed and verified.

Licensee has met the requirements to increase her capacity and has been approved.

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.

Exit interview conducted and report was reviewed with the Licensee, Tiffany Johnson.

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

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2023
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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