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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313622857
Report Date: 06/04/2019
Date Signed: 06/04/2019 10:59:36 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:VAUGHAN, DOLLY & RODRIGUEZ, MARIAFACILITY NUMBER:
313622857
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 3DATE:
06/04/2019
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Dolly VaughanTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Justin Denton met with the licensee Dolly Vaughan for the purpose of a capacity increase from 8 to 14 children. LPA toured all areas of the home that are accessible to children, today’s census included three children. All adults in the home have been finger print cleared through Community Care Licensing.

Off-limit areas include: Main House, Bedroom #4, patio, walking area, and backyard. Licensee acknowledged that children may never enter these off-limit areas. LPA suggested that licensee mark the patio area as "on-limits" because it is marked as an emergency exit pathway. Licensee agreed to send LPA an updated facility sketch.

LPA observed a fire drill was conducted and documented. The Fire Safety Inspection Clearance has been received from the Roseville Fire Department, Roseville, CA and the home has been cleared for up to 14 children.

Licensee acknowledges that when there is no assistant present, facility will revert back to the small capacity. Licensee acknowledges that children residing in the home under the age of 10 years shall be included in capacity.

In the areas that were evaluated, no deficiencies were observed at the time of the visit.

Effective today, 6/4/19, LPA is granting a license to serve 12 children (when there is an assistant present) with no more than 4 infants or capacity of 14 children with 1 child in kindergarten or elementary school and 1 child at least age 6 and a maximum of 3 infants. Infants are children under the age of 2 years old.
SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Justin L DentonTELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2019
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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