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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566206478
Report Date: 01/03/2020
Date Signed: 01/03/2020 02:54:33 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:KISSICK FCC AKA CAMP KISSICKFACILITY NUMBER:
566206478
ADMINISTRATOR:BRENDA I. KISSICKFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 373-1486
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:14CENSUS: 0DATE:
01/03/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Brenda KissickTIME COMPLETED:
03:05 PM
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Licensing Program Analysts (LPAs) Francisco Pedroza and Betzayra Cervantes conducted an unannounced Case Management inspection. LPA's met with licensee Brenda Kissick and her associate Jeff Melnick. LPA's advised the licensee the nature of the inspection. Licensee advised that the facility is closed for the holidays. There were no children in care at the time of the inspection.

Community Care Licensing (CCL) was advised of a recent incident that occurred outside of the facility. Licensing requested information regarding S1. S1 lives in the licensed facility. S1 has been fingerprinted and a background clearance has been completed. S1 does not have an active role in the day care. S1 works a full time job outside the home. Licensee advised that S1 may assist at one point in time if needed in the future. There are no firearms or ammunition in the home. Licensee advised the previous documented firearm was removed when their previous associate moved out of the home.

Given the licensee has completed all the necessary requirements and submitted the required documents to CCL, LPA's deemed licensee is in compliance with all Title 22 regulations.

No deficiencies were cited during today's visit.

THE NOTICE OF SITE VISIT WAS POSTED.
SUPERVISOR'S NAME: George MingleTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco PedrozaTELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2020
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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