Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313615384
Report Date: 04/18/2017
Date Signed 04/18/2017 11:29:59 AM

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 - JUNCTIONFACILITY NUMBER:
313615384
ADMINISTRATOR:GRISWOLD, JANICEFACILITY TYPE:
840
ADDRESS:2150 ELLISON DRIVETELEPHONE:
(916) 772-4988
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:90CENSUS: 0DATE:
04/18/2017
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Janice GriswoldTIME COMPLETED:
11:45 AM
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LPA Keven Peters made an unannounced visit to the facility for the purpose of conducting a Case Management Incident visit. This is in regards to an Unusual Incident Report that was submitted on 04/03/2017 via a phone call to O.D. The incident involved a 6 year old child that was playing tag, she ran into a pole that was supporting the sun shade. Staff called 911, the child was evaluated and released by F. D. Parents arrived and took the child to the doctors where she received stitches over the left eye. LPA interviewed staff, there were no children in care during today’s visit; LPA toured the area where the Unusual Incident occurred. The teachers have spoken with the children regarding being careful. The director had a staff meeting on 04/05/2017 to discuss the incident.

After discussion with staff and observing the area, LPA determined that no Title 22 violations took place.

Report was reviewed with the director, exit interview was conducted.

Notice of site visit posted.

SUPERVISOR'S NAME: Jennifer BrekkeTELEPHONE: (916) 263-5717
LICENSING EVALUATOR NAME: Keven PetersTELEPHONE: (916) 216-7796
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2017
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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