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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 070208034
Report Date: 01/21/2020
Date Signed: 01/21/2020 12:28:45 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:SRVSACCA - KIDS COUNTRY-WALT DISNEYFACILITY NUMBER:
070208034
ADMINISTRATOR:HIATT, MOLLYFACILITY TYPE:
840
ADDRESS:3250 PINE VALLEY ROADTELEPHONE:
(925) 552-4489
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:120CENSUS: 16DATE:
01/21/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Molly HiattTIME COMPLETED:
12:30 PM
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LPA Dayna Collier met with Site Director Molly Hiatt for a case management inspection as a result of receiving an unusual incident report.

As a result of this inspection, there are no deficiencies cited.

A SITE VISIT NOTICE WAS POSTED BY STAFF.
SUPERVISOR'S NAME: Diane PerezTELEPHONE: (510) 622-2590
LICENSING EVALUATOR NAME: Dayna CollierTELEPHONE: (510) 725-7021
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2020
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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