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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343616796
Report Date: 03/02/2022
Date Signed: 03/02/2022 10:34:40 AM


Document Has Been Signed on 03/02/2022 10:34 AM - It Cannot Be Edited

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:33CENSUS: 27DATE:
03/02/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ann Marie DuesburyTIME COMPLETED:
10:45 AM
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At 9:30 a.m. on Wednesday, March 2nd, 2022, Licensing Program Analyst (LPA) Karyn Guerra met with Director, Ann Marie Duesbury, for the purpose of a case management-incident inspection. Facility self reported the incident on February 14th, 2022. An Unusual Incident Report Form LIC624 was received via fax on February 16th, 2022. Incident occurred on February 10th, 2022. During today's inspection, LPA conducted interviews and made observations. No title 22 deficiencies were cited during inspection. A notice of site visit was provided and shall remain posted for a period of 30 days for parental review.
SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Karyn GuerraTELEPHONE: (916) 216-7790
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022
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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