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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 573614564
Report Date: 01/04/2022
Date Signed: 01/04/2022 02:03:32 PM

Document Has Been Signed on 01/04/2022 02:03 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:PEREGRINE PROJECT, THEFACILITY NUMBER:
573614564
ADMINISTRATOR:VALENZUELA CORTEZ, GABRIELFACILITY TYPE:
850
ADDRESS:2907 PORTAGE BAY WESTTELEPHONE:
(530) 758-8845
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: DATE:
01/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Interim Site Supervisor, Heidi AmadorTIME COMPLETED:
02:10 PM
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Licensing Program Analysts (LPAs) Chayntel Hunter and Lauren Scott met with Interim Site Supervisor, Heidi Amador to follow up on the Unusual Incident Reports (UIRs) submitted to Community Care Licensing on 12/15/21 and 12/16/21. During today's visit the facility was toured.

LPAs interviewed the Site Supervisor and teachers who were present during the incidents. The facility reported the UIR to Community Care Licensing within 24hrs. A written UIR was submitted within 7 days, describing the specifics of the incidents.

Facility evaluation report was reviewed and discussed with Interim Site Supervisor. Exit interview was conducted. A notice of site visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

In the areas that were evaluated, no deficiencies were cited during today's inspection.
SUPERVISORS NAME: Justin L Denton
LICENSING EVALUATOR NAME: Chayntel Hunter
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2022
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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