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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 475406089
Report Date: 02/12/2021
Date Signed: 02/12/2021 03:51:22 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:SHASTA HEAD START - MT. SHASTA CENTERFACILITY NUMBER:
475406089
ADMINISTRATOR:FERGUSON, APRILFACILITY TYPE:
850
ADDRESS:710 EVERITT MEMORIAL HWY.TELEPHONE:
(530) 918-2550
CITY:MT. SHASTASTATE: CAZIP CODE:
96067
CAPACITY:20CENSUS: 10DATE:
02/12/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Natalie GilliamTIME COMPLETED:
08:45 AM
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The facility inspection was conducted via video due to the current state of emergency regarding the COVID-19 outbreak. On 2/12/21 at 815 AM, Licensing Program Analyst (LPA) Snow conducted an announced case management inspection and met with Director Natalie Gilliam to discuss a self reported incident occurring on the bus on 2/24/2020.
During the discussion today (2/12/21) The Director confirmed that there have been no further related incidents.
On 11/18/20 @ 11am the LPA discussed the incident with Director, Natalie Gilliam who provided details.

There were no Title 22 deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Jaime SnowTELEPHONE: (530) 215-6132
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2021
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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