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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623008
Report Date: 06/19/2019
Date Signed: 06/19/2019 01:45:53 PM

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:GRAY, LATONIAFACILITY NUMBER:
343623008
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 7DATE:
06/19/2019
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Latonia GrayTIME COMPLETED:
02:00 PM
NARRATIVE
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LPA arrived at the facility for a complaint investigation on 6/19/19. LPA did not observe a current Children's Roster at time of investigation. This is a violation and considered a potential risk to the children in care.

Title 22 deficiencies are cited on the subsequent page of this report. Appeal Rights were provided and an exit interview was conducted. A Notice of Site Visit was posted and must remain posted for 30 days.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Christopher BelloTELEPHONE: (916) 862-0844
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: GRAY, LATONIA
FACILITY NUMBER: 343623008
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/19/2019
Section Cited
HSC
1596.841
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Each child day care facility shall maintain a current roster of children who are provided care in the facility. The roster shall include the name, address, and daytime telephone number of the child's parent or guardian, and the name and telephone number of the child's
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Licensee will provide a current copy of the Children's Roster to the LPA by POC date: 7/19/19.
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physician. This roster shall be available to the licensing agency upon request. This is not met by evidence: LPA did not observe a Chidlren's Roster in the facility at time of investigation. This is considered a potential risk to the children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Christopher BelloTELEPHONE: (916) 862-0844
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2