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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 121374840
Report Date: 05/26/2022
Date Signed: 05/27/2022 11:27:21 AM


Document Has Been Signed on 05/27/2022 11:27 AM - It Cannot Be Edited

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:HEAD START - JEFFERSONFACILITY NUMBER:
121374840
ADMINISTRATOR:ROBERTS, DONNAFACILITY TYPE:
850
ADDRESS:914 B STREETTELEPHONE:
(707) 441-9020
CITY:EUREKASTATE: CAZIP CODE:
95501
CAPACITY:20CENSUS: 0DATE:
05/26/2022
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Abraxas LaytonTIME COMPLETED:
05:00 PM
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 On May 26, 2022 at 2pm the facility by Licensing Program Analyst (LPA), Snow & Lynch went to the administrative office for NORTHCOAST CHILDREN'S SERVICES located at 1266 9th street in Arcata to meet with Abraxas Layton and discuss faucets that tested positive for lead. A follow-up up visit will be made,

No violations were issued today
SUPERVISOR'S NAME: Erin VirruetaTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaime SnowTELEPHONE: (530)215-6132
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022
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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