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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 293621170
Report Date: 03/01/2021
Date Signed: 03/01/2021 10:24:46 AM

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:HECKATHORN, JAAZIELFACILITY NUMBER:
293621170
ADMINISTRATOR:HECKATHORN, JAAZIELFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 470-0226
CITY:NEVADA CITYSTATE: CAZIP CODE:
95959
CAPACITY:14CENSUS: 6DATE:
03/01/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Jaaziel HeckathornTIME COMPLETED:
10:30 AM
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*NOTE: Due to Covid-19 and DPH guidelines on social distancing, a Tele-inspection was conducted via Zoom.*

On Monday, March 1st, 2021, at 9:50am, Licensing Program Analyst (LPA) Blake Morillas conducted a Case Management Tele-inspection in regards to two received Unusual Incident Reports (UIR). When the Licensee was asked how many children were present, she replied that 6 children were present at that time.

The Licensee self reported two incidents. The first incident occurred on 11-5-2020 where a school age child was running on the grass area, tripped, and sustained a fractured arm. The other incident occurred on 2-25-2021 where several school age children were conducting a science experiment for a school assignment, which was to construct a fulcrum. A school age child was inadvertently struck by the fulcrum, requiring stiches for their injury.

With the help of the Licensee, the LPA was shown where the incidents occurred and a conversation was had in regards to the incident. It was determined that no Title 22 violations took place.

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

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: 03/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2021
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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