455404137-10-18-2022-13-CC-BMEZ-CKBPNR-20221018112823

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 455404137
Report Date: 10/18/2022
Date Signed: 10/18/2022 11:28:30 AM

Document Has Been Signed on 10/18/2022 11:28 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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME:	SHASTA HEAD START - COTTONWOOD		FACILITY NUMBER:	455404137
ADMINISTRATOR:	GILLIAM, JANICE		FACILITY TYPE:	850
ADDRESS:	3388 MAIN ST.		TELEPHONE:	(530) 347-6793
CITY:	COTTONWOOD	STATE: CA	ZIP CODE:	96022
CAPACITY:	20	CENSUS: 6	DATE:	10/18/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:17 AM
MET WITH:	Janice Gilliam		TIME COMPLETED:	11:40 AM

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On 10/18/22 at 9:17am, an annual inspection was made to the facility by Licensing Program Analyst (LPA), Mendez. (This program is operated by Head Start and a Title 5 funded program.) Hours of operation are 8am-2pm, Monday–Friday. The facility was toured at 10:30am inside and outside and the floor and yard plan submitted by the licensee were verified. Facility operates in one room

The facility representative and staff were supervising 6 children, and operating within the licensed capacity and ratio requirements. There are no pools or bodies of water on the premises.

Six children's records were reviewed at 9:27am. Five staff records were reviewed at 9:53am.

Facility representative was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

SUPERVISOR'S NAME: Megan Aviles	TELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Bianca Mendez	TELEPHONE: (530) 895-4357
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: SHASTA HEAD START - COTTONWOOD	FACILITY NUMBER: 455404137
	VISIT DATE: 10/18/2022

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This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

There were no deficiencies cited during today’s inspection.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the facility representative Janice Gilliam.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

SUPERVISOR'S NAME: Megan Aviles	TELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Bianca Mendez	TELEPHONE: (530) 895-4357
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022

LIC809 (FAS) - (06/04)

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