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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455407028
Report Date: 06/21/2019
Date Signed: 06/21/2019 04:20:05 PM

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:CLINE, OLGA FAMILY CHILD CARE HOMEFACILITY NUMBER:
455407028
ADMINISTRATOR:CLINE, OLGAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(559) 362-3862
CITY:COTTONWOODSTATE: CAZIP CODE:
96022
CAPACITY:14CENSUS: 3DATE:
06/21/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Olga ClineTIME COMPLETED:
04:25 PM
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A case management inspection was made to the facility by Licensing Program Analysts (LPAs) Chris Krogstad and Pati Pacheco for the purpose of confirming the removal of an individual (Adult #1 - LIC 811 Confidential Names) that has been excluded from residing or being present in the home.

LPAs met with the licensee who stated that Adult #1 was a potential employee/assistant who was never hired and was never present in the home. The home and child care area was toured. Adult #1 was not present. Based on evidence obtained during todays inspection, the LPAs have verified the individual is not present, employed, or residing in the home. Verification of removal is complete.

There were no Title 22 violations observed or cited during today's inspection. This report was read to and reviewed with the licensee.

Notice of Site Visit shall be posted for 30 days.
SUPERVISOR'S NAME: Erin VirruetaTELEPHONE: (530) 895-4325
LICENSING EVALUATOR NAME: Christen KrogstadTELEPHONE: (530) 895-4230
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2019
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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