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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 170110408
Report Date: 01/14/2025
Date Signed: 01/14/2025 01:31:03 PM

Document Has Been Signed on 01/14/2025 01:31 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BEALL, KIM FAMILY CHILD CARE HOMEFACILITY NUMBER:
170110408
ADMINISTRATOR/
DIRECTOR:		BEALL, KIM L.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 263-4093
CITY:LAKEPORTSTATE: CAZIP CODE:
95453
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
01/14/2025
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Kim BeallTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
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On 01/14/2025 at 01:20PM, Licensing Program Analyst, Sebastian Phouthavong made an announced Case Management visit to the facility and met with Licensee, Kim Beall today to verify operation at the facility, and to address the facility's forfeiture. Prior to visit, on 01/14/2025, Licensee notified LPA of the closure.

During the visit, LPA observed no children in care and toured all areas of where care was being provided. There was no evidence of operation and/or childcare being provided at the facility. Licensee stated she is forfeiting her license due to personal reasons and the last day of operation in 2008. LPA received a Statement of closure with Licensee’s signature and date of closure.

The approval the Closure for the Family Child Care Home have been met.

Exit interview conducted and report was reviewed with Licensee, Kim Beall

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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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