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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 033607205
Report Date: 06/26/2019
Date Signed: 06/26/2019 01:34:54 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:AMADOR-TUOLUMNE COMMUNITY ACTION AGENCY HEAD STARTFACILITY NUMBER:
033607205
ADMINISTRATOR:BUCHANAN, SANDYFACILITY TYPE:
850
ADDRESS:108 WEST MARLETTE ST.TELEPHONE:
(209) 274-0395
CITY:IONESTATE: CAZIP CODE:
95640
CAPACITY:20CENSUS: 8DATE:
06/26/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Tiana MohrTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Justin Denton conducted an unannounced case management inspection regarding an incident report received on 6/10/19.

Upon arrival, Staff Tiana Mohr informed LPA that the incident report listed the incorrect facility as located at 108 West Marlette Street, Ione, CA. The facility Summerville Head Start is actually located at 18451 Carter Street in Tuolumne, CA. (553607282) LPA confirmed that no one going by the name of the staff member mentioned in the incident report has worked at the facility in Ione (033607205).

LPA determined that the address provided on the incident report is incorrect and should list the facility in Tuolumne. Staff informed LPA that Summerville operates from 9AM to 3PM, but is currently closed until the beginning of August.

No deficiencies were cited at this time.

A copy of this report was left with the facility.
SUPERVISOR'S NAME: Sharon OgbodoTELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Justin L DentonTELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2019
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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