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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 310305284
Report Date: 03/01/2021
Date Signed: 03/01/2021 02:26:03 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:KIDZCOMMUNITY - FORESTHILL HEAD START (PS)FACILITY NUMBER:
310305284
ADMINISTRATOR:GOARD, NANCYFACILITY TYPE:
850
ADDRESS:24745 HARRISON ST.TELEPHONE:
(530) 367-2847
CITY:FORESTHILLSTATE: CAZIP CODE:
95631
CAPACITY:24CENSUS: 11DATE:
03/01/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:49 PM
MET WITH:Pamela French - Site SupervisorTIME COMPLETED:
02:30 PM
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*NOTE: Due to Covid-19 and DPH guidelines on social distancing, a Tele-inspection was conducted via Phone Call with Picture Messages.*

On Monday, March 1st, 2021, at 1:49pm, Licensing Program Analyst (LPA) Blake Morillas conducted a Case Management Tele-inspection in regards to the received Unusual Incident Report (UIR). When the Site Supervisor was asked how many children were present, she replied that 11 children and 4 staff are present.

It was self reported that on 2-4-2021, a child was playing on the climbing bars and was disembarking from the structure in a manner they have successfully done several times before. However when demonstrating to their teacher, the child lost their grip, fell, and suffered a fracture.

With the help of the Site Supervisor, the LPA was shown, via picture messages, where the incident occurred and a conversation was had in regards to said incident. It was determined that no Title 22 violations had happened.

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

The report was reviewed with the Site Supervisor 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 Site Supervisor 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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