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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 125401062
Report Date: 04/26/2023
Date Signed: 04/26/2023 09:52:14 AM


Document Has Been Signed on 04/26/2023 09:52 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 - FORTUNAFACILITY NUMBER:
125401062
ADMINISTRATOR:HOUSEWORTH, MELISSAFACILITY TYPE:
850
ADDRESS:2085 NEWBURG ROADTELEPHONE:
(707) 725-6532
CITY:FORTUNASTATE: CAZIP CODE:
95540
CAPACITY:60CENSUS: 26DATE:
04/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:45 AM
MET WITH:Melissa HouseworthTIME COMPLETED:
09:56 AM
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On 4/26/23 at 7:45am, an annual inspection was made to the facility by Licensing Program Analyst (LPA), Mendez. (This program is operated by (public agency/Head Start) and a Title 5 funded program.) Class 2 operates 8:15-11:45am Monday-Thursday 12:30pm 4:00pm Monday-Friday, Class 1 operates 8:00am-5:00pm Monday–Friday. The facility was toured at 9:30am inside and outside and the floor and yard plan submitted by the licensee were verified. The facility representative and staff were supervising 26 children, and operating within the licensed capacity and ratio requirements. There are no pools or bodies of water on the premises. The outdoor activity space was cushioned with rubber mats and grass and free of hazards.

Facility representative was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

SUPERVISOR'S NAME: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Bianca MendezTELEPHONE: (530) 895-4357
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: HEAD START - FORTUNA
FACILITY NUMBER: 125401062
VISIT DATE: 04/26/2023
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There were no deficiencies cited during today’s inspection.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the facility representative Melissa Houseworth

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

SUPERVISOR'S NAME: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Bianca MendezTELEPHONE: (530) 895-4357
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
LIC809 (FAS) - (06/04)
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