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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
045408064
Report Date:
04/21/2022
Date Signed:
04/21/2022 01:40:30 PM
Document Has Been Signed on
04/21/2022 01:40 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
CCLD Regional Office
,
520 COHASSET RD., SUITE 170
CHICO
,
CA
95926
FACILITY NAME:
APPLEGATE, TRACIE FAMILY CHILD CARE HOME
FACILITY NUMBER:
045408064
ADMINISTRATOR:
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
CITY:
STATE:
ZIP CODE:
CAPACITY:
8
TOTAL ENROLLED CHILDREN:
8
CENSUS:
0
DATE:
04/21/2022
TYPE OF VISIT:
Case Management - Licensee Initiated
UNANNOUNCED
TIME BEGAN:
01:20 PM
MET WITH:
Jeremy Applegate
TIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Emilia Grisak conducted a follow-up inspection to verify that pool fencing meets Title 22 requirements and that there is a fire extinguisher rated at least 2A10BC present in the home. LPA toured the pool area and observed that it is surrounded by a fence that is at least 5 feet tall and extends to the ground and has a gate with a self-closing self-latching device with the self-latching device located no more than 6 inches from the top of the gate. LPA also verified that the mobile home located next to the home is off-limits by means of door locks.
The facility is ready to be licensed.
SUPERVISORS NAME
:
Erin Virrueta
LICENSING EVALUATOR NAME
:
Emilia Grisak
LICENSING EVALUATOR SIGNATURE
:
DATE:
04/21/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/21/2022
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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