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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010038
Report Date: 03/01/2023
Date Signed: 03/01/2023 12:26:40 PM

Document Has Been Signed on 03/01/2023 12:26 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:EL, SHELDON FCCHFACILITY NUMBER:
493010038
ADMINISTRATOR:EL, SHELDONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 708-8676
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 14TOTAL ENROLLED CHILDREN: 9CENSUS: 7DATE:
03/01/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
11:43 AM
MET WITH:Yvonne PenaTIME COMPLETED:
12:35 PM
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A required inspection visit was made to the facility by Licensing Program Analyst (LPA) Amy Strother. LPA met with Assistant, Yvonne Pena (S1). A review of staff records indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. S1 stated that there are presently two adults living in the home, S1 and the Licensee. S1 was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

During today’s visit, two assistants were supervising children, 3 infants and 4 preschool age children and operating within the licensed capacity and ratio requirements. S1 stated there are currently no children off site. S1 provided a current roster of children in care as required. LPA verified that all children present were listed on the roster. LPA reviewed S1's pediatric first aid/CPR certificate is current and expires on 5/2024.

There were no Title 22 deficiencies cited during today's inspection.

An exit interview was conducted and report was reviewed with assistant, Yvonne Pena.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2023
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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