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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073402542
Report Date: 09/25/2020
Date Signed: 09/25/2020 11:30:26 AM

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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:PAYTON, PATFACILITY NUMBER:
073402542
ADMINISTRATOR:PAYTON, PATFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 439-3963
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY:14CENSUS: 4DATE:
09/25/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Pat PaytonTIME COMPLETED:
11:45 AM
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On 09/25/2020 LPA Miller met with licensee Pat Payton on a announced case management inspection for the purpose of inspecting a new play structure and trampoline. LPA inspected the trampoline, it is bolted to the ground and is secured, no rips, loose bolts, or sharp edges. LPA also inspected the new play structure, it is bolted down, secured, no visible broken pieces or sharp edges. The swings are secured and can hold LPAs weight, slide is also secured in place. Both the play structure and trampoline have sufficient padding underneath.

No deficiencies cited today. Exit interview conducted with Pat Payton and she was provided a copy of notice of site visit.

Notice of site visit was posted at the time of the inspection and must remain posted for 30 days. Failure to keep this notice posted for the 30 consecutive days will result in an immediate civil penalty.

A copy of this report shall be maintained for 3 years and available for public review upon request.

SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Jaylena MillerTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2020
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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