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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313620610
Report Date: 08/04/2020
Date Signed: 08/04/2020 01:08:16 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:FARREN, JUNEFACILITY TYPE:
840
ADDRESS:6811 CAMBORNE WAYTELEPHONE:
(916) 788-7141
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY:60CENSUS: 6DATE:
08/04/2020
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Susan TuckerTIME COMPLETED:
01:15 PM
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LPA Amanda Blesi met with interim Director Susan Tucker via Facetime due to State of Emergency, Shelter in Place COVID-19. The CDI after school program is requesting permission to temporarily use the Multipurpose Room on the Sierra Elementary School Campus while they deep clean their current room. Ms. Tucker estimates they will use the room for Wednesday and Friday and then return to their regular classroom.

The use of the Multipurpose room is approved for temporary use during the two day period.

Notice of Site Visit provided via email and shall be posted for 30 days.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amanda BlesiTELEPHONE: (916) 208-3427
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2020
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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