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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313602634
Report Date: 07/18/2019
Date Signed: 07/18/2019 09:33:53 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:TANNER, MARYFACILITY NUMBER:
313602634
ADMINISTRATOR:TANNER, MARYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 878-9266
CITY:AUBURNSTATE: CAZIP CODE:
95602
CAPACITY:14CENSUS: 5DATE:
07/18/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Mary TannerTIME COMPLETED:
09:55 AM
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Licensing Program Analyst (LPA) Blake Morillas conducted a unannounced Case Management visit in regards to received Unusual Incident Reports (UIR). LPA informed the Licensee, Mary Tanner, of the reason for the inspection. Upon arrival there were 3 Preschool age and 2 School Age children present.

The Licensee self reported two separate incidents on 6-28-2019 where at two separate times, two different children sustained minor injuries while in the play yard.

LPA toured the day care facility where the incident occurred and interviewed the Licensee in regards to the incident, after which it was determined that no Title 22 violations took place.

Report was reviewed with the Licensee and an exit interview was conducted.

Notice of site visit posted.

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

DATE: 07/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2019
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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