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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490109272
Report Date: 07/24/2023
Date Signed: 07/24/2023 02:50:26 PM


Document Has Been Signed on 07/24/2023 02:50 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 RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:4CS PETALUMA CHILD DEVELOPMENT CENTERFACILITY NUMBER:
490109272
ADMINISTRATOR:SENAN, IMANFACILITY TYPE:
850
ADDRESS:401 S MC DOWELLTELEPHONE:
(707) 544-3077
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY:52CENSUS: DATE:
07/24/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jenny CopelandTIME COMPLETED:
02:57 PM
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Licensing Program Analysts (LPAs) Robert Maciel and Glenn Ouye met with Site supervisor Iman Senan for a final inspection of the facility before switching to active status.

During the tour of the facility, site supervisor stated that the facility is still waiting on changing the west, east, and south fencing, installing five trees against the southern fence, filling in a depression on the north side of the facility with bark, replacing the wood chips in the front with soft pore fall protection and setting up the play ground equipment on top of it.

Facility has sufficient furniture, equipment, and toys for the children.
License was given to site supervisor.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert MacielTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2023
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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