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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 033607205
Report Date: 05/23/2023
Date Signed: 05/23/2023 12:56:05 PM


Document Has Been Signed on 05/23/2023 12:56 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
SACRAMENTO SOUTH, 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: 13DATE:
05/23/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Site Supervisor: Paula Consolo TIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Mariya Melnichuk met with Site Supervisor, Paula Consolo to follow up on an Unusual Incident Report (UIR) submitted to Community Care Licensing on 5/19/2023 . During today's visit the facility was toured. Present were 13 preschool age children in care and 3 staff.

LPA interviewed the Site Supervisor who was present during the incident. LPA reviewed and discussed this report with the Site Supervisor.

The facility reported the UIR to Community Care Licensing within 24hrs. A written UIR was submitted within 7 days, describing the specifics of the incident.

Site Supervisor stated that on 5/19 a child was running outside, tripped and fell and hit his face of a knee another child while falling. The child had a bloody nose and swelling on his face. Staff handled the incident with proper first aid precautions and contacted the parent immediately. The child was picked up by mom and taken to the hospital shortly. LPA toured the yard where the child fell and did not see any safety hazards.

Facility evaluation report was reviewed and discussed with Site Supervisor. Exit interview was conducted. A notice of site visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

In the areas that were evaluated, no deficiencies were cited during today's inspection.
SUPERVISOR'S NAME: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR NAME: Mariya MelnichukTELEPHONE: (916) 917-9273
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2023
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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