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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483010152
Report Date: 03/14/2024
Date Signed: 03/14/2024 11:38:25 AM

Document Has Been Signed on 03/14/2024 11:38 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:BAISDEN-NICKELBERRY, SHEREE' FCCHFACILITY NUMBER:
483010152
ADMINISTRATOR:B-NICKELBERRY SHERFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 342-9797
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
03/14/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:No one homeTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Glenn Ouye arrived to do a confirmation of closure. LPA just spoke with the licensee who said that she moved out of this location on February 20, 2024. She now resides at 1268 Sereno Dr. Vallejo. There was no answer when LPA rang doorbell. There were no cars in the driveway. The home appeared vacant.
No signature on file at licensee was at her new home and no one answered the door.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Glenn Ouye
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2024
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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