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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393615424
Report Date: 03/14/2022
Date Signed: 03/14/2022 11:11:24 AM


Document Has Been Signed on 03/14/2022 11:11 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:GRIGSBY EARLY CARE AND LEARNING CENTERFACILITY NUMBER:
393615424
ADMINISTRATOR:MARTIN, ROCHELLEFACILITY TYPE:
850
ADDRESS:6600 GRIGSBY PLACETELEPHONE:
(209) 952-9334
CITY:STOCKTONSTATE: CAZIP CODE:
95219
CAPACITY:57CENSUS: 11DATE:
03/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Rochelle Martin, Site SupervisorTIME COMPLETED:
11:20 AM
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Licensing Program Analysts (LPAs) Lauren Scott and Chayntel Hunter met with Site Supervisor, Rochelle Martin to follow up on an Unusual Incident Report (UIR) submitted to Community Care Licensing on 03/09/2022 regarding an incident that took palce 3/8/2022. During today's visit the facility was toured. Present were 11 children in care and 4 staff.

LPAs interviewed the Site Supervisor and the two teachers who were present during the incident. Site Supervisor stated the outdoor drum set the child fell off, was lowered, and discussed possible removal of equipment.

The facility reported the UIR to Community Care Licensing within 24hrs. A written UIR was submitted within 7 days, describing the specifics of the incident.

Facility evaluation report was reviewed and discussed with Site Supervisor. Exit interview was conducted. A notice of site visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

In the areas that were evaluated, no deficiencies were cited during today's inspection.
SUPERVISOR'S NAME: Justin L DentonTELEPHONE: (916) -92-9269
LICENSING EVALUATOR NAME: Lauren ScottTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022
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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