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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313620613
Report Date: 07/29/2020
Date Signed: 07/29/2020 01:36:39 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 - ROCKLIN (SA)FACILITY NUMBER:
313620613
ADMINISTRATOR:ZIMMERLING, MATHEWFACILITY TYPE:
840
ADDRESS:5025 MEYERS STREETTELEPHONE:
(916) 624-3311
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY:62CENSUS: 20DATE:
07/29/2020
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jessica AnayaTIME COMPLETED:
01:45 PM
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LPA Amanda Blesi met with Director Jessica Anaya via Facetime due to State of Emergency, Shelter in Place COVID-19. The CDI after school program is requesting permission to temporarily use room #39 on the Rocklin Elementary School Campus while they disinfect their current room due to a possible COVID-19 exposure. Room 39 will be utilized by school age children only. Ms. Anaya estimates they will use the room for two days and then return to their regular classroom.

LPA has received a copy of the school fire clearance and is approving the temporary use of room #39 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: 07/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2020
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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