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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 293619733
Report Date: 06/04/2019
Date Signed: 06/04/2019 12:27:44 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:ROBYN, JESSICAFACILITY NUMBER:
293619733
ADMINISTRATOR:ROBYN, JESSICAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 615-6908
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY:14CENSUS: 5DATE:
06/04/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Jessica RobynTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Blake Morillas conducted an unannounced Case Management visit for the purpose of inspecting the recently constructed above ground pool. The Licensee contacted the LPA regarding the installation of an above ground. Upon arrival there were 2 School Age and 3 Preschool Age children in care.

The pool is surrounded by a 5 ft tall fence, with a self latching gate that swings away from the body of water.

LPA observed the fence, gate, latch, and it appeared all aspects of the fencing met Title 22 regulations.

The report was reviewed with the Licensee and an exit interview was conducted.

Notice of site visit to be posted for 30 days.

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

DATE: 06/04/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2019
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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