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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 170110857
Report Date: 10/27/2022
Date Signed: 10/27/2022 09:34:40 AM

Document Has Been Signed on 10/27/2022 09:34 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:SULLIVAN, TERRIE FAMILY CHILD CARE HOMEFACILITY NUMBER:
170110857
ADMINISTRATOR:SULLIVAN, TERRIEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 263-3598
CITY:LAKEPORTSTATE: CAZIP CODE:
95453
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
10/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Terrie SullivanTIME COMPLETED:
09:40 AM
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On 10/27/2022, at 8:50, Licensing Program Analyst, Sebastian Phouthavong made an unannounced Case Management visit to the facility and met with Licensee, Terrie Sullivan and Licensee’s spouse, to verify operation at the facility, and to address the facility's forfeiture. Prior to visit, Licensee submitted a certification of non-operation to CCL.

During the visit, LPA observed no children in care and toured the room of where care was being provided. There was no evidence of operation and/or childcare being provided at the facility. Licensee stated she has retired after working for many years. LPA received a copy of the license with Licensee’s signature and date of closure. Licensee kept the original copy of the License for memorabilia purposes and will not be used for operation of a Family Child Care Home. The approval the Closure for the Family Child Care Home has been met.


Exit interview conducted and report was reviewed with the licensee, Terrie Sullivan.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2022
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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