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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 125407167
Report Date: 06/01/2023
Date Signed: 06/01/2023 11:04:27 AM


Document Has Been Signed on 06/01/2023 11:04 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
CHICO-DAY CARE, 520 COHASSET RD., SUITE 170
CHICO, CA 95926



FACILITY NAME:LEVI-LUSTER, JENNIFER FAMILY CHILD CARE HOMEFACILITY NUMBER:
125407167
ADMINISTRATOR:LEVI-LUSTER, JENNIFERFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 443-9080
CITY:EUREKASTATE: CAZIP CODE:
95501
CAPACITY:14CENSUS: 9DATE:
06/01/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Jennifer Levi-LusterTIME COMPLETED:
11:30 AM
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An inspection was conducted by Licensing Program Analysts (LPA) Kiriko Lynch and Noah Wheeler for the purpose of confirming the removal of an excluded individual at the facility. LPAs met with the Licensee who stated the individual does not live, is not present or employed at the facility, and Licensee also confirmed that she is aware that the individual is not permitted to be in the facility at any time when children are in care. LPAs toured all the rooms of the facility, and observed the excluded individual was not present. LPAs also verified LIC 995B forms were in facility files at the time of the visit. Based on evidence obtained during today's visit, the LPAs have verified the individual is not present, employed, or residing at the facility. LPAs have advised the Licensee to disassociate the individual from their roster, and Licensee stated she agrees to remove individual from her roster at the time of the visit. Verification of removal is complete.

No Title 22 regulations were cited at today's visit. Exit interview conducted with Licensee, Notice of Site Visit posted.
SUPERVISOR'S NAME: Erin VirruetaTELEPHONE: (530) 966-0216
LICENSING EVALUATOR NAME: Kiriko LynchTELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023
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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