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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 053613073
Report Date: 09/05/2019
Date Signed: 09/05/2019 11:45:16 AM

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:GARANT, MICHELLEFACILITY NUMBER:
053613073
ADMINISTRATOR:GARANT, MICHELLEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 772-7267
CITY:VALLEY SPRINGSSTATE: CAZIP CODE:
95252
CAPACITY:14CENSUS: 4DATE:
09/05/2019
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Bailey PolinskyTIME COMPLETED:
12:00 PM
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LPA Denton made unannounced visit to verify correction of deficiencies cited on previous visit. LPA met with staff, Bailey Polinsky.

The following deficiencies were cited during visit conducted 8/28/19:
102417(g)(4): Operation of a Family Care Home.

Upon arrival to the home LPA observed the kitchen knives were stored inaccessibly to children in a latched kitchen drawer.

LPA observed a child safety lock on the door knob to the laundry room and child safety latches on the bathroom cabinet under the sink.

No Title 22 deficiencies cited during today's visit.

Notice of site visit posted.

Exit interview conducted.
SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Justin L DentonTELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2019
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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