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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 503604009
Report Date: 11/12/2019
Date Signed: 11/12/2019 09:57:07 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:CCCDS - STONUM CHILD DEVELOPMENT CENTERFACILITY NUMBER:
503604009
ADMINISTRATOR:CAMBRIA RIVASFACILITY TYPE:
850
ADDRESS:1336 STONUM ROADTELEPHONE:
(209) 581-9180
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY:42CENSUS: 34DATE:
11/12/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Cambria RivasTIME COMPLETED:
10:00 AM
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Licensing Program Analysts (LPAs) Rene Mancinas JR and Angelica Mejia, conducted an unannounced case management inspection. LPAs met with Site Supervisor, Cambria Rivas, and took a census. The purpose of today’s inspection was to follow up on an incident that was reported to Community Care Licensing on 10/31/2019. The incident reported involved child #1 tripping on the steps of the outdoor play structure and falling, resulting in an injury that required medical attention.

During today’s inspection, LPAs inspected the outdoor play structure. The play structure was age appropriate and in good condition, free of any hazards, such as broken areas. LPAs also observed adequate cushioning surrounding the play structure and new slip guards that were installed on the steps of the play structure on 11/7/2019. The play structure had previous slip guards fixed in place, but after the incident, additional slip guards were installed as additional safety measures.

Per California Code of Regulations Title 22 Division 12 Chapter 1, no deficiency is being cited today. Notice of Site Inspection to be posted for 30 days.

SUPERVISOR'S NAME: Susie FanningTELEPHONE: (559) 650-7890
LICENSING EVALUATOR NAME: Rene MancinasTELEPHONE: (559) 341-4524
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2019
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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