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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483008836
Report Date: 12/17/2021
Date Signed: 12/17/2021 01:04:08 PM

Document Has Been Signed on 12/17/2021 01:04 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:TABIQUE, MELISSA FCCHFACILITY NUMBER:
483008836
ADMINISTRATOR:TABIQUE, MELISSAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 853-3585
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
12/17/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Melissa Tabique TIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA), Melchisedeck Augustin conducted an unannounced Case Management visit at the facility to address an outstanding annual fee balance of $210. During today's visit, there were no daycare children in care and the Licensee was provided with the opportunity to pay her annual fee balance in full and the Licensee provide proof of payment receipt to LPA. The Licensee also completed and submitted an LIC 9211 to request the facility's inactive status be extended from 07/22/21 through 07/14/22. The facility fee is paid in full and the facility's inactive status will be extended until 07/14/22. LPA reminded the Licensee that failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license. This report was reviewed and discussed with the Licensee. There were no Title 22 deficiencies cited at this time. Notice of Site Visit shall be posted for 30 days.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2021
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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