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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313620600
Report Date: 05/11/2020
Date Signed: 05/12/2020 08:09:36 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:CLUB ROCKLIN CDI - ROCK CREEK (SA)FACILITY NUMBER:
313620600
ADMINISTRATOR:SHALON WARNERFACILITY TYPE:
840
ADDRESS:2140 COLLET QUARRY DRTELEPHONE:
(916) 788-4282
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:60CENSUS: 8DATE:
05/11/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Shalon WarnerTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Jeremey McClain conducted an unannounced Tele-Inspection with Site Supervisor Shalon Warner. The purpose of the inspection was to follow up on the Unusual Incident Report received via fax on 05/05/2020.

LPA confirmed a census of eight children supervised by two staff members during the inspection.

It was reported that on 04/30/2020, a child ran away from a teacher and the facility, while being followed by staff on foot and by staff in a car. Rocklin Police Department was contacted during the incident and retrieved the child on Park Dr., approximately 10 minutes after the child ran away from the facility. The child was brought back to facility without any injuries.

During today’s inspection, LPA interviewed staff involved during the incident. Interviews were consistent that staff maintained supervision of the child after they had left the facility. LPA determined there was no violation Title 22 Regulations as a result of the incident.

LPA sent this report to Shalon Warner for review and signature via email. LPA also provided a Notice of Site Visit which shall remain posted for 30 days.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Jeremey McClainTELEPHONE: (916) 216-7801
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2020
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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