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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009907
Report Date: 07/22/2022
Date Signed: 07/22/2022 12:09:11 PM

Document Has Been Signed on 07/22/2022 12:09 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:WADDELL, ANTOINISHA FCCHFACILITY NUMBER:
483009907
ADMINISTRATOR:WADDELL, ANTOINISHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 373-3363
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
07/22/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:06 AM
MET WITH:Licensee unavailable for signatureTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA), Melchisedeck Augustin made an announced Case Management visit to verify operation status of the facility. On 07/19/22, the Licensee submitted a written statement to the Department to notify she mailed her facility license, as well as the facility was closed.

During today's visit, the Licensee (LS) was not present and unavailable for LPA to tour the facility indoor and outdoor on limit areas. LPA did not see or hear any daycare child(ren) in the home and there was no indication that a childcare facility was being operated in the home. At 11:21am, LPA made a telephone to the LS who confirmed she closed the facility on 07/17/22, she no longer resided in the home and moved out of the home on 07/21/22. The facility license is forfeited in accordance with California Code of Regulations (CCR) 102383(a)(1), and the license will be closed effective, 07/22/2022.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2022
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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