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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 485407403
Report Date: 08/09/2024
Date Signed: 08/09/2024 01:25:34 PM

Document Has Been Signed on 08/09/2024 01:25 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:SIMONS, CHRISTINE FAMILY CHILD CARE HOMEFACILITY NUMBER:
485407403
ADMINISTRATOR/
DIRECTOR:		SIMONS, CHRISTINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 365-8757
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
08/09/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:10 PM
MET WITH:Licensee unavailableTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA), Melchisedeck Augustin made an unannounced Case Management (CM) visit for the purpose of verify the facility's operational status. On 08/05/24, the Licensee (LS) notified the department that she moved out of the residence and ceased operation of the daycare on 06/27/24, due to personal reason(s).

During today's visit, LPA knocked on the facility entrance and the resident of the home confirmed she recently moved into the residence, and she did not know LS. There was/were no evidence to suggest that an active childcare facility was being operated on the premise. The facility license is forfeited in accordance with CCR 102383(a)(1), and the license will be closed effective, 08/09/2024. LS was unavailable to provide a signature and/or to discuss and review the report.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2024
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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