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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515408137
Report Date: 08/29/2024
Date Signed: 08/29/2024 12:48:53 PM

Document Has Been Signed on 08/29/2024 12:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO CC RO, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:BROWN, KIMBERLY FAMILY CHILD CARE HOMEFACILITY NUMBER:
515408137
ADMINISTRATOR/
DIRECTOR:		BROWN, KIMBERLYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 774-3368
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
08/29/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Kimberly Brown TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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On 8/29/24 LPA Elizabeth Friese conducted a case management visit and met with Licensee Kimberly Brown.
Upon receiving the roster during a previous inspection, it was later observed to be incomplete. Parent and physician contact, and dates were observed to be missing or inaccurate.
By record review, the following violation of the California Code of Regulations, Title 22; Division 12, were observed: 1596.841 (see LIC 809D).

Appeal Rights were provided and report was reviewed and discussed with licensee Kimberly Brown.

Notice of Site Visit shall be posted for 30 days from today's visit.
SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Elizabeth Friese
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
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 08/29/2024 12:48 PM - It Cannot Be Edited


Created By: Elizabeth Friese On 08/29/2024 at 12:20 PM
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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: BROWN, KIMBERLY FAMILY CHILD CARE HOME
FACILITY NUMBER: 515408137

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/29/2024
Section Cited
CCR
1596.841

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Current roster of children provided care in facility required-..... day care facility shall maintain a current roster of children who are provided care in the facility...shall include the name, address, and daytime telephone number of the child's parent or guardian... and physician.
This requirement was not met as evidenced by:
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LIcensee will provide current and accurate roster to CCLD by 9/29/24.
elizabeth.friese@dss.ca.gov
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 The roster obtained was missing names and phone numbers for parents, physician's and address. Dates were missing or incorrect.
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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:Erin Virrueta
LICENSING EVALUATOR NAME:Elizabeth Friese
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


LIC809 (FAS) - (06/04)
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