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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 093614391
Report Date: 07/30/2019
Date Signed: 07/30/2019 11:14:02 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:MS. LISA'S MONTESSORIFACILITY NUMBER:
093614391
ADMINISTRATOR:HAYES, LISAFACILITY TYPE:
830
ADDRESS:2558 GREENWOOD LANETELEPHONE:
(530) 676-9393
CITY:CAMERON PARKSTATE: CAZIP CODE:
95682
CAPACITY:10CENSUS: 6DATE:
07/30/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Lisa HayesTIME COMPLETED:
11:30 AM
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Licensing Program Analysts (LPAs), Jan Hoshida and Tanya Washington, met with owner and director, Lisa Hayes, for a case management inspection on this date to discuss the unusual incident report (UIR) that the program submitted and which occurred on 7/12/2019. LPA observed six infants with three staff present.

LPA conducted interviews and observed care and supervision of children in care.

No deficiencies were cited in today’s inspection.

Exit interview and notice of site visit was posted.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Jan HoshidaTELEPHONE: (916) 917-6572
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2019
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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