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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 203810070
Report Date: 10/04/2019
Date Signed: 10/04/2019 04:22:03 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:YOSEMITE LAKES COMMUNITY CHURCH KIDS IN CHRISTFACILITY NUMBER:
203810070
ADMINISTRATOR:HECKMAN, BRENDAFACILITY TYPE:
840
ADDRESS:43840 PATRICK AVETELEPHONE:
(559) 440-6777
CITY:COARSEGOLDSTATE: CAZIP CODE:
93614
CAPACITY:42CENSUS: 16DATE:
10/04/2019
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:AndreaTIME COMPLETED:
05:00 PM
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LPA Brannon met with school age director, Andrea Warren. During today's visit, LPA Brannon picked up updated documentation. LPA took a census and toured the facility. LPA observed three supervising 16 school age children.

Per California Code of Regulations Title 22, Division 12, no deficiency cited. Exit interview conducted with director, Andrea Warren. A copy of this report need to be placed in facility file for public review. A Notice of Site Visit was posted on parent board.

The following documents should be posted at the facility:
Ø PUB 269 – child passenger restraint systems poster
Ø PUB 393 – Notification of Parents Rights
Ø License
Ø Menus
Ø LIC 613A – Personal Rights form
Ø LIC 610 – Disaster Plan
Ø LIC 9148 – Earthquake Preparedness Checklist

A COPY OF THIS REPORT IS TO REMAIN IN THE FACILITY FOR PUBLIC REVIEW.
THIS REPORT SHALL BE MADE AVAILABLE TO THE PUBLIC UPON REQUEST.
To order forms, etc. visit our website at www.ccld.ca.gov
SUPERVISOR'S NAME: Michael DuarteTELEPHONE: (559) 650-7874
LICENSING EVALUATOR NAME: Cynthia BrannonTELEPHONE: (559) 341-5155
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2019
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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