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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 173009456
Report Date: 02/02/2024
Date Signed: 02/02/2024 09:16:18 AM

Document Has Been Signed on 02/02/2024 09:16 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:JAUREGUI, ROSELIA FCCHFACILITY NUMBER:
173009456
ADMINISTRATOR:JAUREGUI, ROSELIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 400-4193
CITY:CLEARLAKESTATE: CAZIP CODE:
95422
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
02/02/2024
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:TIME COMPLETED:
09:15 AM
NARRATIVE
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On 02/02/2024, at 8:30AM, Licensing Program Analyst, Sebastian Phouthavong made an announced Case Management visit to the facility and to verify operation at the facility, and to address the facility's forfeiture. Prior to visit, on 02/01/2024, Licensee notified LPA for the forfeiture and has not operated at the home since 2019. Licensee stated she is no longer a resident at the home.

During the visit, LPA observed the home from the front. There was no evidence of operation and/or childcare being provided at the facility. LPA did hear new residences living at the home, but confirmed by the Licensee that there no affiliation with them. Licensee stated she is ceasing her operation for a Family Child Care Home due to personal reasons.

Once Licensee has submits documentation on the forfeiture to the department, the approval the Closure for the Family Child Care Home will be met.

Facility Representative signature not available at this time.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2024
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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