Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493008113
Report Date: 09/19/2019
Date Signed: 09/20/2019 10:04:27 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:HEAD START - MARTINEZ & GUILLORY CENTERFACILITY NUMBER:
493008113
ADMINISTRATOR:LISA GROCOTTFACILITY TYPE:
850
ADDRESS:10288 STARR ROADTELEPHONE:
(707) 837-0917
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY:40CENSUS: 37DATE:
09/19/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:51 PM
MET WITH:Josefina Figueroa and Teresa DiazTIME COMPLETED:
02:09 PM
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An unannounced case management inspection was conducted by Licensing Program Analyst (LPA) Y. Yang for the purpose of confirming the removal of an excluded individual, Weizen Frias (S1). LPA met with the center directors Josefina Figueroa (S2) and Teresa Diaz (S3), who stated S1 is not at the facility. The center directors stated that S1's last day at the center was on May 28, 2019. Center director S2 and S3 confirmed that they are aware that the individual is not permitted to be in the facility at any time when children are in care. LPA toured the entire facility, and the excluded individual was not present.

Based on evidence obtained during today's visit, LPA has verified that the individual is not present, employed, or residing at the facility. LPA advised the facility to disassociate the individual from their roster. The licensee understands and is aware that an immediate $500 Civil Penalty will be assessed for having any adults work or live in the facility without background clearance. Verification of removal is complete. This report was reviewed and discussed with the center directors S2 and S3. All Licensing reports are public information, and must be made available upon request for at least three years.

Notice of Site Visit shall be posted for 30 days from today's inspection.

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

Verification of removal is complete.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang YangTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2019
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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