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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313622857
Report Date: 08/07/2020
Date Signed: 08/07/2020 09:20:22 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:VAUGHAN, DOLLY & RODRIGUEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 275-6230
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:14CENSUS: 6DATE:
08/07/2020
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Dolly Vaughn -LicenseeTIME COMPLETED:
09:30 AM
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An announced case management virtual video tour inspection was conducted today by LPA Owens, due to COVID-19. LPA met with licensee, Dolly Vaughan via Face-Time. The purpose of the case management virtual video tour was to have the back yard put on-limits. LPA observed the complete backyard via virtual video. There is a small shed-house in the backyard that is used for her dogs. This small shed-house will remain off-limit by way of being behind a fence. The grass area will be on-limits for children use. There are no bodies of water, no pool and no obvious hazardous. The grass area in the backyard is now on limits for day care children use.

No deficiencies.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Katrina OwensTELEPHONE: 916-263-6280
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2020
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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