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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 293606323
Report Date: 01/09/2020
Date Signed: 01/09/2020 12:43:12 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:OUR KIDS' PLACEFACILITY NUMBER:
293606323
ADMINISTRATOR:CAROL VIOLAFACILITY TYPE:
850
ADDRESS:10846 GILMORE WAYTELEPHONE:
(530) 274-9106
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY:45CENSUS: 26DATE:
01/09/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Carol Viola - Program DirectorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Blake Morillas and Licensing Program Manager (LPM) K. Peters conducted a unannounced Case Management visit in regards to a received Unusual Incident Report (UIR). LPA informed the Program Director, Carol Viola, of the reason for the inspection. Upon arrival there were 26 preschool children present along with 4 staff.

The Program Director self reported an incident on 11-21-2019 where a child was physically guided to the classroom from the playground by one of the staff.

LPA toured the day care facility where the incident occurred and spoke with the Program Director in regards to the incident, after which it was determined that no Title 22 violations took place.

Report was reviewed with the Program Director and an exit interview was conducted.

Notice of site visit posted.

SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Blake MorillasTELEPHONE: (916) 208-3734
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2020
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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