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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009296
Report Date: 04/13/2023
Date Signed: 04/13/2023 03:24:52 PM

Document Has Been Signed on 04/13/2023 03:24 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:PALOMBO, SHANNON FCCHFACILITY NUMBER:
493009296
ADMINISTRATOR:PALOMBO, SHANNONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 658-2301
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
04/13/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Shannon PalomboTIME COMPLETED:
10:16 AM
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A case management visit was made to the facility today by Licensing Program Analyst (LPA) Y.Yang to conduct a confirmation of facility closure visit. The facility's licensee, Shannon Palombo submitted a request to close her facility on 04/04/23. During today's case management visit, the LPA observed no children in care or any evidence of childcare being provided at this address. A tour of the home was provided to the LPA by the licensee. The LPA provided the licensee with a confirmation of facility closure receipt letter during this visit.

Confirmation of facility closure is complete.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Yang Yang
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2023
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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