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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009829
Report Date: 03/01/2022
Date Signed: 03/01/2022 11:11:37 AM

Document Has Been Signed on 03/01/2022 11:11 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SUTLIFF, JESSICA FCCHFACILITY NUMBER:
483009829
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
03/01/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Licensee Jessica SutliffTIME COMPLETED:
10:53 AM
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Licensing Program Anaylst ( LPA ) Elpidia Hernandez Torres arrived to facility to provide technical assistance and to review floor plan changes. Licensee submitted application for increase of capacity on 02/ 08/2022, during the next three weeks licensee would Mail out back and fourth with Regional Office Application for increase of capacity and fee. Licensee received two check lists from support staff asking for missing application forms. Licensee called LPA Hernandez Torres on 02/28/2022 requesting assistance with documents sent and what is missing from the increase of capacity application. LPA provided a list with the names of the forms needed for the increase of capacity application, LPA advised licensee to make copies of the documents and to keep them should they go missing in the mail again, and LPA advised Licensee to mail out the completed increase of capacity application with the fee together as one mailed item. Licensee stated she would refill out the forms and mail them out today as one complete packet. While LPA was in the home, LPA toured the recently converted " Off Limits" to " On Limits". The facility sketch was verified.

There were no Title 22 deficiencies cited today.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2022
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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