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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455406395
Report Date: 09/12/2022
Date Signed: 09/12/2022 01:34:12 PM


Document Has Been Signed on 09/12/2022 01:34 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/12/2022 11:58 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO-DAY CARE, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

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This is an amended report. On 09/12/22 at 11:00 a.m., Licensing Program Analyst (LPA) N. Cunningham conducted a Case Management visit to the home for the purpose of providing the licensee with the Order to Licensee/Facility for Immediate Exclusion for Kohl Hendrix. LPA also provided Order to Individual for Immediate Exclusion From All Facilities addressed to Kohl Hendrix.

LPA provided LIC 995B (Addendum to Notification of Parents' Rights) and explained that the licensee is required to notify each parent or authorized representative of the exclusion and obtain their signature on LIC995b. There were no Title 22 deficiencies cited during today's visit.

Notice of Site Visit shall be posted for 30 days
SUPERVISOR'S NAME: Erin VirruetaTELEPHONE: (530) 966-0216
LICENSING EVALUATOR NAME: Nicolette CunninghamTELEPHONE: (530) 521-5235
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2022
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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