Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313619903
Report Date: 08/25/2015 12:00:00 AM
Date Signed 08/25/2015 09:41:52 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:GRIFFIN, JENNIFERFACILITY NUMBER:
313619903
ADMINISTRATOR:GRIFFIN, JENNIFERFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 899-1887
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:14CENSUS: 7DATE:
08/25/2015
TYPE OF VISIT:Annual/RequiredUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Jennifer GriffinTIME COMPLETED:
09:50 AM
NARRATIVE
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Licensing Program Analyst (LPA) Keven Peters met with licensee for an annual/required visit and toured areas of the home accessible to the children. Off-limit areas include the back deck.. Licensee acknowledged that children may never enter these off-limit areas. The census included 3 infants, and 4 preschool age children. Licensee stated there are no new residents in the home, and all adult residents have criminal record clearances.

LPA observed current CPR/First Aid certificates (expired 1/2016), posted License, Parents' Rights Poster and Emergency Disaster Plan. LPA reviewed children's records and client roster.

LPA observed hazardous items properly stored out of children's reach. A fireplace containing a screen was observed. Licensee stated there are no weapons in the home. Fire extinguisher and smoke detector meet regulation. LPA observed fire drills documented on a calendar. Toys appear to be safe and in working order. The backyard is fenced,and there were no bodies of water.

LPA provided the Licensing Agency website (www.ccld.ca.gov), so the licensee may obtain updated licensing information, regulations, and forms.



No deficiencies were cited on todays visit.
Exit interview conducted. Notice of Site Visit was posted.
SUPERVISOR'S NAME: Jennifer BrekkeTELEPHONE: (916) 263-5717
LICENSING EVALUATOR NAME: Keven PetersTELEPHONE: (916) 216-7796
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2015
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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