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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 344500083
Report Date: 01/07/2021
Date Signed: 01/07/2021 02:18:38 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:SCRUGGS, PAULINEFACILITY NUMBER:
344500083
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 4DATE:
01/07/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Pauline ScruggsTIME COMPLETED:
01:45 PM
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Due to the COVID-19 pandemic Licensing Program Analyst (LPA) Fabiola Diaz is conducting a tele-inspection with licensee Pauline Scruggs. The purpose of today's tele-inspection is a case management to follow up regarding a self reported unusual incident report (UIR) called in to Community Care Licensing on 11/23/2020. The written UIR was submitted to the Department on 12/01/20 and then resubmitted with additional sections completed on 12/14/20. Four day care children were present during today's tele-inspection. Licensee's adult daughter was also present. LPA observed the facility.

No Title 22 deficiencies were cited today. An Advisory Note-Technical Violation was issued today 1/07/2021 discussing children’s records. An exit interview was conducted. A copy of this report was e-mailed to licensee to keep on file at the facility. A “read receipt” and/or an e-mail from licensee stating licensee has read and reviewed this report is in lieu of a signature due to COVID-19. Licensee stated she is able to sign the LIC 809 report and e-mail back to LPA.
SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 263-2002
LICENSING EVALUATOR NAME: Fabiola DiazTELEPHONE: (916) 206-9352
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2021
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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