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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 085402644
Report Date: 03/12/2020
Date Signed: 03/12/2020 03:41:28 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:MARY PEACOCK STATE PRESCHOOLFACILITY NUMBER:
085402644
ADMINISTRATOR:HIRT, LARAFACILITY TYPE:
850
ADDRESS:1720 ARLINGTON DRIVETELEPHONE:
(707) 464-0301
CITY:CRESCENT CITYSTATE: CAZIP CODE:
95531
CAPACITY:24CENSUS: 3DATE:
03/12/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Missie FergusonTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Kiriko Lynch visited the center today for the purpose of a case management - incident, which was reported by the facility on 02/12/20. LPA met with Lead Teacher, and inspected the area where the incident occurred. LPA interviewed staff regarding care and supervision on the day of the incident, and obtained the written report regarding the incident. LPA did not observe or note any violations.

No Title 22 deficiencies were cited during today's visit. Notice of Site Visit posted.
SUPERVISOR'S NAME: Erin VirruetaTELEPHONE: (530) 895-4325
LICENSING EVALUATOR NAME: Kiriko LynchTELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2020
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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