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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313608491
Report Date: 05/01/2019
Date Signed: 05/01/2019 09:16:31 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:ADVENTURE CLUB - COYOTE RIDGEFACILITY NUMBER:
313608491
ADMINISTRATOR:SISNEROZ, VICKIFACILITY TYPE:
840
ADDRESS:1751 MORNINGSTARTELEPHONE:
(916) 772-7271
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:120CENSUS: 0DATE:
05/01/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Brandy Hopkins - Assistant DirectorTIME COMPLETED:
09:30 AM
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Licensing Program Analyst (LPA) Blake Morillas conducted a unannounced Case Management visit in regards to a received Unusual Incident Report (UIR). LPA informed the Assistant Director, Brandy Hopkins, of the reason for the inspection. Upon arrival there were no school age children present.

The self reported UIR noted that on 4-22-2019, a child sustained injury during a fall while on the playground.

LPA toured the day care facility where the incident occurred to ensure adequate padding was in place around the play structure and interviewed staff regarding the incident.

It was determined that no Title 22 violations took place.

Report was reviewed with the Assistant Director 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: 05/01/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2019
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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