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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 053622109
Report Date: 03/23/2021
Date Signed: 03/23/2021 01:59:43 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:HENDERSON, JENNIFERFACILITY NUMBER:
053622109
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 13DATE:
03/23/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jennifer HendersonTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Justin Denton met with the Licensee Jennifer Henderson for the purpose of a capacity increase inspection from 8 to 14 children. LPA virtually toured all areas of the home that are accessible to children. Today’s census included 13 children. All adults in the home have been fingerprint cleared through Community Care Licensing. This inspection was conducted virtually due to the ongoing COVID-19 pandemic.

Off-limit areas include master bedroom, master bathroom, son's bedroom, and garage. Licensee acknowledged that children may never enter these off-limit areas.

LPA observed that a fire drill was conducted and documented. The Fire Safety Inspection Clearance has been received from the Calaveras County Consolidated Fire District and the home has been cleared for up to 14 children.

Licensee acknowledges that when there is no assistant present, facility will revert back to the small capacity. Licensee acknowledges that children residing in the home under the age of 10 years shall be included in capacity.

In the areas that were evaluated, no deficiencies were observed at the time of the inspection.

Effective today, 03/23/2021, LPA is granting a license to serve 12 children (when there is an assistant present) with no more than 4 infants or capacity of 14 children with 1 child in kindergarten or elementary school and 1 child at least age 6 and a maximum of 3 infants. Infants are children under the age of 2 years old.
SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Justin L DentonTELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2021
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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