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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313620610
Report Date: 09/09/2019
Date Signed: 09/09/2019 02:30:42 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:CLUB ROCKLIN CDI - SIERRA (SA)FACILITY NUMBER:
313620610
ADMINISTRATOR:TUTTLE, MATTHEWFACILITY TYPE:
840
ADDRESS:6811 CAMBORNE WAYTELEPHONE:
(916) 788-7141
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY:60CENSUS: 44DATE:
09/09/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Matthew TuttleTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Amanda Blesi met with director Matthew Tuttle for a random annual inspection. This facility is located on Sierra Elementary School grounds in Portable B, The facility operates Monday through Friday from 7:00 A.M. to 6:00 P.M. The facility provides breakfast, lunch and one snacks for the children. LPA toured the facility including all activity/classroom areas, the isolation area and food service area. LPA reviewed care and supervision of children, staffing ratios, health related services, furniture, equipment, drinking water and food service provisions. The facility uses the elementary school playground and the elementary school bathrooms. LPA reviewed the children's Identification and Emergency Information. LPA reviewed personnel's education and immunization requirements. All staff currently employed with the center have criminal record clearances and are associated to the Sunset Ranch site facility # 313620604 waiver on file. At least one staff member present today has current EMSA approved Pediatric/Child CPR and First Aid.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm
To order forms please visit our website at www.ccld.ca.gov

Per California Code of Regulations, Title 22, Division 12, Chapter 1, no deficiencies are cited during today's inspection.

Licensing report was reviewed and discussed with director.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amanda BlesiTELEPHONE: (916) 208-3427
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2019
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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