Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 065402559
Report Date: 06/01/2017
Date Signed: 06/09/2017 04:42:35 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:WILLIAMS CHILDREN'S CENTERFACILITY NUMBER:
065402559
ADMINISTRATOR:GARZA, ANAFACILITY TYPE:
830
ADDRESS:501 THEATER DRIVETELEPHONE:
(530) 473-2246
CITY:WILLIAMSSTATE: CAZIP CODE:
95987
CAPACITY:40CENSUS: 4DATE:
06/01/2017
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Sylvia Navarro, Area ManagerTIME COMPLETED:
03:55 PM
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A Case Management inspection was made to the facility by LPA Laura Chavez in response to a self reported Unusual Incident Report received 5/26/2017 involving a child breaking his leg while at the center. On Thursday, 5/25/2017 at approximately 9:30am, child #1 (see LIC 811,Confidential Names) placed a small rubber ball on the ground in the outdoor play area. The child missed the ball after attempting to kick it, fell forward onto the ball, rolled off landing on his right leg. The incident occurred on the grassy area of the outdoor play area. The child was provided immediate care by staff #1 (See LIC 811, Confidential Names) and the child's mother was immediately contacted. The child was taken to the hospital and was diagnosed with a broken leg. Two staff were supervising 6 children in the outdoor play area when the incident occurred.

At this time there is no violation of Title 22 Regulations.

This and all licensing reports are public documents and are to be made available upon request.
SUPERVISOR'S NAME: Jordan MonathTELEPHONE: (530) 513-1214
LICENSING EVALUATOR NAME: Laura ChavezTELEPHONE: (530) 895-5914
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2017
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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