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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393622973
Report Date: 07/13/2023
Date Signed: 07/13/2023 02:12:37 PM

Document Has Been Signed on 07/13/2023 02:12 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:JAMES, MEGANFACILITY NUMBER:
393622973
ADMINISTRATOR:MEGAN JAMESFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 810-1961
CITY:LODISTATE: CAZIP CODE:
95242
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
07/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Licensee, Megan JamesTIME COMPLETED:
02:30 PM
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On 07/13/23, Licensing Program Analyst (LPA) Tobias Lake arrived at the facility for the purpose of a case management visit to follow up on an incident that occurred on 06/16/23 and was met with the Licensee, Megan James. During today's inspection LPA toured the home and obtained documents pertaining to the incident. The Facility reported the Unusual Incident to Community Care Licensing within 24 hours. A written UIR was submitted within 7 days, describing the specifics of the incident.

The notice of site visit was posted where the parent/guardian of children enter and exit the facility. The Notice of Site Visit must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

Report was discussed with the Licensee and an exit interview was conducted.
SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Tobias Lake
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2023
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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