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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343622070
Report Date: 01/19/2023
Date Signed: 01/19/2023 10:36:26 AM

Document Has Been Signed on 01/19/2023 10:36 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:COLVARD, TIFFANYFACILITY NUMBER:
343622070
ADMINISTRATOR:COLVARD, TIFFANYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 373-4087
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 15DATE:
01/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Dasa IonTIME COMPLETED:
11:00 AM
NARRATIVE
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On January 19, 2023, Licensing Program Analysts (LPAs) Amanda Sutter and Amanda Blesi arrived at the facility for the purpose of interviewing a child for a complaint unrelated to this facility. Upon arrival, LPAs observed 15 children supervised by two staff. Assistant stated that licensee was out of town on vacation with her husband and would be returning the following day.

Based on the inspection, one Title 22 Deficiencies has been issued on the attached LIC 809-D. The assistant was informed that this report dated 1/19/2023 documents one Type A citation related to capacity which shall be posted for 30 consecutive days. The licensee shall also provide a copy of this licensing report to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification. Assistant has been provided with appeal rights.

Exit interview conducted and report was reviewed with staff Dasa Ion. A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Amanda Sutter
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2023
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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Document Has Been Signed on 01/19/2023 10:36 AM - It Cannot Be Edited


Created By: Amanda Sutter On 01/19/2023 at 10:08 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: COLVARD, TIFFANY
FACILITY NUMBER: 343622070

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/20/2023
Section Cited
CCR
102416.5

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102416.5 Staffing ration and capacity (a) The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time.
This regulation was not as evidenced by:
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LPAs observed one child leave the facility at 10:25 AM.
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Based on observation, there were 15 daycare children in care upon arrives, which poses an immediate health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Seychelle De Luca
LICENSING EVALUATOR NAME:Amanda Sutter
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023


LIC809 (FAS) - (06/04)
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