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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009859
Report Date: 08/21/2023
Date Signed: 08/21/2023 09:41:38 AM

Document Has Been Signed on 08/21/2023 09:41 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:HLINKA, SUSIE & HLINKA, AMY FCCHFACILITY NUMBER:
493009859
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 0TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
08/21/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:TIME COMPLETED:
09:35 AM
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On 8/21/23 Licensing Program Analyst (LPA) Selena Mariani conducted an unannounced site visit to confirm closure. LPA Selena spoke with Stephen Dobrow who stated that he is the new owner of the home, there is no child care being provided and the previous owners moved out of state.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Selena Mariani
LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2023
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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