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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 173002889
Report Date: 01/08/2020
Date Signed: 01/08/2020 01:29:26 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:YUBA COMMUNITY COLLEGE,LAKE CAMPUS CDCFACILITY NUMBER:
173002889
ADMINISTRATOR:BLAKE, CHERYLFACILITY TYPE:
850
ADDRESS:15880 DAM ROAD EXTENSIONTELEPHONE:
(707) 995-7909
CITY:CLEARLAKESTATE: CAZIP CODE:
95422
CAPACITY:30CENSUS: 22DATE:
01/08/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Cheryl Blake, DirectorTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) N. Cunningham conducted a case management inspection regarding an incident report submitted to CCL on 11/15/19. LPA met with the Director and stated the reason for the visit.

On 11/14/19, child (C1) pushed a toy vehicle from the top of the blue slide down the slide. C1 followed the toy vehicle down the slide on their belly. Approximately 2 feet from the ground, C1 went over the side of the slide and landed on top of the toy vehicle on the ground. LPA inspected and photographed the location of the incident. LPA observed the slide in good condition and sufficient cushioning around the slide. LPA interviewed the Director who observed this incident. A review of records and interview with the Director indicate that staff provided adequate care and supervision and provided immediate care to the injured child. Staff also documented the injury and notified the child's authorized representative in a timely manner. Based on the interview conducted and records reviewed, this facility used all available resources to ensure the health and safety of children in care and could not feasibly have prevented C1's injury in the moment.

Notice of Site Visit shall be posted for 30 days from today's visit.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Nicolette CunninghamTELEPHONE: (707) 588-5056
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2020
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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