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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343616796
Report Date: 06/02/2021
Date Signed: 06/02/2021 10:54:05 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:OUR LADY OF THE ASSUMPTIONFACILITY NUMBER:
343616796
ADMINISTRATOR:DUESBURY, ANN MARIEFACILITY TYPE:
850
ADDRESS:5055 COTTAGE WAYTELEPHONE:
(916) 485-1504
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:30CENSUS: 0DATE:
06/02/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ann Marie DuesburyTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Gagandeep Singh met with the director, Ann Marie Duesbury, for a case management inspection. The purpose of the inspection was explained. The facility informed the Department that the facility will be using different classroom and play yard for day care and requested for capacity increase to 33 children in care.

During today's inspection, LPA toured the new classrooms, bathrooms and Play yard with the director. There is no furniture in the classroom and no play structure in the play yard. Per director, facility will be receiving the furniture and play structure and have them installed by the month of July. Per director, the fire inspection was conducted and clearance was granted. The Department has not received the clearance form from the fire department. LPA asked the director to keep the Department informed about the getting the new classrooms ready. LPA informed the director that once the classroom and play yard get ready, another inspection will be conducted.

Copy of this report reviewed and provided to the director. An exit interview was conducted. Notice of site visit was posted and shall remain posted for next 30 days.
SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Gagandeep SinghTELEPHONE: (916) 216-7823
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021
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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