<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 293619733
Report Date: 04/14/2021
Date Signed: 04/14/2021 01:46:52 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: 8DATE:
04/14/2021
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
01:17 PM
MET WITH:Jessica Robyn - LicenseeTIME COMPLETED:
01:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
*NOTE: Due to Covid-19 and DPH guidelines on social distancing, a Tele-inspection was conducted via Google Duo.*

On Wednesday, April 14th, 2021, at 1:17pm, Licensing Program Analyst (LPA) Blake Morillas conducted a Case Management Tele-inspection for the purpose of inspecting a recently installed pool in the Licensee's back yard. When the Licensee was asked how many children were present, she replied that 8 children were present at that time.

Before the Tele-inspection, the Licensee submitted a signed Applicant/Licensee Bodies of Water Checklist, indicating that the pool fencing meets Title 22 regulations for bodies of water.

The fenced area where the pool has been set up has been previously inspected by the LPA and was found to be within regulations at that time. At 1:18pm, the Licensee proceeded to show the LPA the fenced area and with a tape measure, showed the overall vertical measurement of the fence along with the measurements between the wooden slats. The gate to the area was also opened and was shown to self close and self latch. From what was observed via the Tele-Inspection, it appeared all aspects of the fencing met Title 22 regulations.

Please note: When a physical inspections takes place, requests for alterations may be made.

At 1:43pm the report was reviewed with the Licensee and an exit interview was conducted.
Notice of site visit to be posted for 30 days.

This report and a Notice of Site Visit will be delivered to the Licensee electronically. Acknowledgement of delivery will constitute acknowledgement of the report in lieu of a signature.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Blake MorillasTELEPHONE: (916) 208-3734
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1