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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 573622056
Report Date: 01/03/2024
Date Signed: 01/03/2024 01:00:55 PM

Document Has Been Signed on 01/03/2024 01:00 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
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ESCAMILLA, DONITAFACILITY NUMBER:
573622056
ADMINISTRATOR:ESCAMILLA, DONITAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 921-6498
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
01/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Licensee, Donita EscamillaTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Lauren Scott met with Licensee, Donita Escamilla to conduct a case management inspection regarding an Unusual Incident Report (UIR) submitted on 9/26/23. The UIR was regarding a child who received an injury needing medical attention.

It was determined that a child was injured while in care by a coffee mug. Although the licensee was able to provide visual supervision, the coffee mug was left within arms reach of the child, which caused an injury resulting in stitches.

Facility evaluation report was reviewed and discussed with the Licensee. An exit interview was conducted. Appeal Rights and Notice of Site Visit were provided by LPA. Notice of Site Visit must remain posted for 30 days.

The following Title 22 Deficiency is being cited on the subsequent 809-D page.
SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: Lauren Scott
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2024
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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