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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 125401215
Report Date: 07/01/2019
Date Signed: 07/01/2019 05:03:28 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:JURAK, LEIA FAMILY DAY CAREFACILITY NUMBER:
125401215
ADMINISTRATOR:JURAK, LEIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 442-0182
CITY:EUREKASTATE: CAZIP CODE:
95503
CAPACITY:14CENSUS: 10DATE:
07/01/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Leia JurakTIME COMPLETED:
05:15 PM
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Licensing Program Analysts (LPAs) Kiriko Lynch and Jaime Snow visited the home today for the purpose of a case management - incident inspection self-reported by the Licensee on 06/20/19. LPAs met with Licensee, toured the home, and investigated the site and play equipment related to the incident. LPAs inspected the site and play equipment, and made recommendations regarding the play equipment in terms of use and placement. Licensee stated she understood and will follow the LPAs recommendations.

No Title 22 deficiencies were cited during today's visit. Exit interview conducted, and 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: 07/01/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2019
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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