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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 123007003
Report Date: 08/16/2023
Date Signed: 08/16/2023 12:01:48 PM


Document Has Been Signed on 08/16/2023 12:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO-DAY CARE, 520 COHASSET RD., SUITE 170
CHICO, CA 95926



FACILITY NAME:MACY, MARY FCCHFACILITY NUMBER:
123007003
ADMINISTRATOR:MACY, MARYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 725-1525
CITY:FORTUNASTATE: CAZIP CODE:
95540
CAPACITY:14CENSUS: 9DATE:
08/16/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Mary MacyTIME COMPLETED:
12:30 PM
NARRATIVE
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LPA Lynch arrived at the home for another visit, and observed the Licensee's facility roster was not updated with current parent contact information for the majority of parents listed on the document. Licensee stated she has the current contact information and updated the roster during the visit. See next page for Title 22 deficiency cited.
SUPERVISOR'S NAME: Erin VirruetaTELEPHONE: (530) 966-0216
LICENSING EVALUATOR NAME: Kiriko LynchTELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023
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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Document Has Been Signed on 08/16/2023 12:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO-DAY CARE, 520 COHASSET RD., SUITE 170
CHICO, CA 95926


FACILITY NAME: MACY, MARY FCCH
FACILITY NUMBER: 123007003

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/16/2023
Section Cited
CCR
102417

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Operation of a Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.
This requirement was not met as evidenced by Licensee's roster was not
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Licensee updated roster during the visit, POC cleared at the time of the visit.
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updated with current phone contact information for the majority of currently enrolled children/parents.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Erin VirruetaTELEPHONE: (530) 966-0216
LICENSING EVALUATOR NAME: Kiriko LynchTELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2