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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009829
Report Date: 01/25/2022
Date Signed: 01/25/2022 03:32:51 PM

Document Has Been Signed on 01/25/2022 03:32 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:SUTLIFF, JESSICA FCCHFACILITY NUMBER:
483009829
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
01/25/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
02:52 PM
MET WITH:Licensee Jessica SutliffTIME COMPLETED:
03:40 PM
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Licensing Program Analyst ( LPA) Elpidia Hernandez Torres met with Licensee for the purpose of making additional areas of the home "On Limits". LPA Received and reviewed the updated facility sketch to show the following areas of the home as on limits; Kids room, Living room, Bathroom, and backyard. The off limit areas of the home are the; Kitchen, garage, laundry room and entire 2nd level. The Stairs have been barricaded with a child safety gate. The Fire place has been barricaded with a child safety gate. Licensee will begin to use the additional on limit areas as of 01/31/2022.

Notice of site visit will be posted for 30 days. No title 22 deficiencies were sited.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2022
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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