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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525407743
Report Date: 06/16/2020
Date Signed: 06/19/2020 02:37:40 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:MEDINA, CAMILLE FAMILY CHILD CARE HOMEFACILITY NUMBER:
525407743
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 4DATE:
06/16/2020
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Camille MedinaTIME COMPLETED:
03:00 PM
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The facility inspection was conducted via tele-inspection due to the current state of emergency regarding the COVID-19 outbreak. The licensee requested a case management visit in relation to her setting up an above ground pool with temporary fencing. The LPA observed that pool chemicals were locked in a cabinet in the licensee's bedroom with a combo lock. LPA observed that the chain link see thru fence was measured at 6 feet tall and surrounds the pool. Fence is anchored by metal support at corners and is anchored on wood fence and is weight bearing. Self latching device is observed to be 6 " from top of gate and gate has a key lock. The gate is self closing and swings away from the pool and the fence and gate presents with a 3.5 " gap. The pool is an 36" intex easy up pool. No ladder is used and no platform is on site. The licensee will provide 100% supervision during the times the pool is in use and agrees to use it according to the manufactures directions.

No deficiencies were cited during today's tele visit.


Notice of Site Visit shall be posted for 30 days from today's visit.
SUPERVISOR'S NAME: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Carrie WisehartTELEPHONE: (530) 895-5824
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2020
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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