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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393609094
Report Date: 12/02/2020
Date Signed: 12/02/2020 04:16:07 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:WALKER, HAZEL & WARREN, SHIRLEYFACILITY NUMBER:
393609094
ADMINISTRATOR:WALKER, HAZEL LEEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 932-9030
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:14CENSUS: 3DATE:
12/02/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Hazel Walker and Shirley WarrenTIME COMPLETED:
03:28 PM
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Due to the COVID-19 pandemic Licensing Program Analyst (LPA) Fabiola Diaz is conducting a tele-inspection via Facetime, with licensees Hazel Walker and Shirley Warren. The purpose of today's visit is a case management inspection to follow up regarding a self reported unusual incident report (UIR) submitted to Community Care Licensing on 09/14/2020. A written UIR was submitted within 7 days, describing the specifics of the incident.Three day care children were present during today's tele-inspection. LPA observed the facility.

No Title 22 deficiencies were cited today based on record reviews, interviews, and observations. An exit interview was conducted. A copy of this report was e-mailed to licensees to keep on file at the facility. A “read receipt” and/or an e-mail from licensees stating licensees have read this report is in lieu of a signature due to COVID-19. Licensees stated they are also able to sign the report and provide a copy to LPA.
SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 263-2002
LICENSING EVALUATOR NAME: Fabiola DiazTELEPHONE: (916) 206-9352
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2020
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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