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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010038
Report Date: 06/21/2023
Date Signed: 06/21/2023 10:50:34 AM

Document Has Been Signed on 06/21/2023 10:50 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: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:
06/21/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Yvonne PenaTIME COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA), Amy Strother conducted a follow up Plan of Correction (POC) visit and met with assistant, Yvonne Pena (S1) for the purpose of following up on a Type B deficiency that was cited on 05/09/23, with a due date of 05/30/23. On 05/09/23 L1 was cited based on her being absent from the home in exceedance of 20 present of the hours that the facility is providing care per day. On 06/08/23 LPA Strother made a POC visit and issued a civil penalty based on the above deficiency not being corrected. Based on interview, L1 has continued to not be present at the facility and has not met the POC. A civil penalty of $100 per day is hereby assessed for the period of 06/09/23 through 06/21/23 for failure to correct the violation for a total of $1,300. See LIC421FC.

Report was reviewed with the 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: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2023
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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