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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 11:05:32 AM

Document Has Been Signed on 06/21/2023 11:05 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:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Yvonne PenaTIME COMPLETED:
11:10 AM
NARRATIVE
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LPA Strother made an unannounced follow up visit to the facility. LPA met with assistant, Yvonne Pena (S1). During today’s visit, LPA asked if Licensee Sheldon El would be present today, S1 stated that she wasn’t sure but did not think so. LPA had emailed L1 on 06/14/23 informing her that her annual fees were past due, and a late fee accessed. LPA provided L1 with a link to a website where the fees can be paid and a PIN to use along with L1’s facility number to pay the fees online. On 06/19/23 LPA sent a follow up email reminding L1 to pay her annual fee and late fee. Based on record review on 06/21/23, L1’s fees have not been paid.

The following violation of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided.

Exit interview conducted and report was reviewed with 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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Document Has Been Signed on 06/21/2023 11:05 AM - It Cannot Be Edited


Created By: Amy Strother On 06/21/2023 at 10:54 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: EL, SHELDON FCCH
FACILITY NUMBER: 493010038

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/28/2023
Section Cited
CCR
102384(a)

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An applicant or licensee shall be charged fees as specified in Health and Safety Code Section 1596.803:



This requirement was not met as evidenced by:
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The licensee will pay annual fees and provide proof that the annual fees have been paid to LPA Strother by 06/28/23 via email.
Email: [email protected]
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Based on record review the licensee has not yet paid her licensing fee.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alexis Hollon
LICENSING EVALUATOR NAME:Amy Strother
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2023


LIC809 (FAS) - (06/04)
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