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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 293623143
Report Date: 05/17/2021
Date Signed: 05/17/2021 02:16:48 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:ALLEN, JENNIFERFACILITY NUMBER:
293623143
ADMINISTRATOR:ALLEN, JENNIFERFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 913-2088
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY:14CENSUS: 7DATE:
05/17/2021
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
01:29 PM
MET WITH:Jennifer Allen - LicenseeTIME COMPLETED:
02:20 PM
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*NOTE: Due to Covid-19 and DPH guidelines on social distancing, a Tele-inspection was conducted via FaceTime.*

On Monday, May 17th, 2021, at 1:29pm, Licensing Program Analyst (LPA) Blake Morillas conducted a Case Management Tele-inspection for the purpose of inspecting the Spa and recently installed Pool and Pool Fence in the Licensee's back yard. When the Licensee was asked how many children were present, she replied that 7 children and a helper were present at that time.

Before the Tele-inspection, the Licensee submitted a signed Applicant/Licensee Bodies of Water Checklist, indicating that the Pool, Pool Fencing and Spa Cover meets Title 22 regulations for bodies of water.

The Licensee proceeded to show the LPA the Spa and cover, with the cover being able to support the weight of an adult (demonstrated by the Licensee) and locked on all four sides. The Licensee then showed the LPA the pool fencing which was 5' 5" high, made of non-climbable material, and had a self closing, self latching gate (demonstrated by the Licensee). From what was observed via the Tele-Inspection, it appeared all aspects of the Spa and Pool Fencing met Title 22 regulations.

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

At 2:13pm, 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 via email. 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: 05/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2021
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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