Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313610190
Report Date: 09/21/2017
Date Signed 09/21/2017 03:07:26 PM

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:ADVENTURE CLUB-THOMAS JEFFERSONFACILITY NUMBER:
313610190
ADMINISTRATOR:SALCI, CAROLFACILITY TYPE:
840
ADDRESS:750 CENTRAL PARK DRIVETELEPHONE:
(916) 774-5169
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:60CENSUS: 13DATE:
09/21/2017
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Brianna Schmidt, Assistant DirectorTIME COMPLETED:
03:30 PM
NARRATIVE
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LPA Amanda Blesi is at the facility today to conduct a complaint investigation. During the course of the visit, a deficiency was observed that is unrelated to the complaint allegations. LPA a staff member present today who had a fingerprint clearance however was not associated to the facility.




Per Chapter 3, Division 12, Title 22 of the California code of Regulations, the following deficiencies are found: See next page 809-D. Appeal Rights provided.


Upon receipt, the licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. Signed receipt should be kept in each child's file.

Report was discussed with assistant director.
Notice of Site Visit posted.
SUPERVISOR'S NAME: Jennifer BrekkeTELEPHONE: (916) 263-5717
LICENSING EVALUATOR NAME: Amanda BlesiTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2017
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: ADVENTURE CLUB-THOMAS JEFFERSON
FACILITY NUMBER: 313610190
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/22/2017
Section Cited
CCR
101170(e)(2)
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Criminal Record Clearance. Prior to working or volunteering in a licensed child care facility, all individuals subject to a criminal record review shall request a transfer of a criminal record clearance from another facility or Trustline.
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Director shall ensure that the employee is associated to the main facility fingerprint Fiddyment Farm facility #313617646.

This shall be done within 24 hours.
Civil Penalties do not apply to this facility.
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Employee Sofia Wolsleben had a fingerprint clearance, however she was not associated to the facility or the Fiddyment Farm Facility.
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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: Jennifer BrekkeTELEPHONE: (916) 263-5717
LICENSING EVALUATOR NAME: Amanda BlesiTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2017
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2017
LIC809 (FAS) - (06/04)
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