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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009050
Report Date: 04/26/2023
Date Signed: 04/26/2023 01:39:29 PM

Document Has Been Signed on 04/26/2023 01:39 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ONLY, BILLIE FCCHFACILITY NUMBER:
483009050
ADMINISTRATOR:ONLY, BILLIEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 704-0699
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
04/26/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:58 PM
MET WITH:Licensee is unavailableTIME COMPLETED:
01:40 PM
NARRATIVE
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Licensing Program Analyst (LPA), Melchisedeck Augustin made an unannounced Case Management visit for the purpose of addressing the facility’s outstanding fee of $210 that was due by 09/11/22 and expired inactive status which expired on 09/11/22. The Department provided the Licensee (LS) with multiple reminders including mailing a letter to remind of the non-payment of fee on 04/20/23 and the license would be forfeited for non-payment, however; the Licensee did not respond.

During today’s attempted visit, LPA observed a "For Sale" sign posted in front of the home and LS was not home. LPA did not see any children present and there was no indication that a childcare facility was being operated in the home. LPA had a limited of the home through view through the window which revealed that the furnishings were moved, shuffled, and appeared to be disorganized.

The facility license is forfeited in accordance with Health and Safety Code 1596.803(e), and the license will be closed effective, 04/26/2023. LS was unavailable for signature.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2023
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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