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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343618158
Report Date: 10/06/2021
Date Signed: 10/06/2021 11:45:02 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:WARD, KORIEFACILITY NUMBER:
343618158
ADMINISTRATOR:WARD, KORIEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 677-7611
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:14CENSUS: 7DATE:
10/06/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Korie Ward - LicenseeTIME COMPLETED:
11:45 AM
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An unannounced case management inspection was conducted today by LPA Owens. LPA Owens met with licensee, Kori Ward. Present at time of inspection was licensee, her husband, her assistant and 7 day care children.

The purpose of the inspection was to address an unusual incident that was self reported by the licensee that occurred on May 10, 2021. LPA Owens toured the back yard where the incident occurred.

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

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
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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