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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 125408329
Report Date: 08/10/2023
Date Signed: 08/10/2023 03:31:23 PM

Document Has Been Signed on 08/10/2023 03:31 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
CHICO-DAY CARE, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:CAL POLY HUMBOLDT CHILDREN'S CENTERFACILITY NUMBER:
125408329
ADMINISTRATOR:WILSON, ELIZABETH-ANNEFACILITY TYPE:
850
ADDRESS:1350 C STREETTELEPHONE:
(707) 826-3838
CITY:ARCATASTATE: CAZIP CODE:
95521
CAPACITY: 58TOTAL ENROLLED CHILDREN: 40CENSUS: 0DATE:
08/10/2023
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Betsy WilsonTIME COMPLETED:
04:00 PM
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LPA K. Lynch conducted a case management visit to amend a location change/prelicensing inspection report from 08/09/2023. LPA met with the facility representative, provided amended reports, and conducted an exit interview. No Title 22 deficiencies cited during today's visit.
SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Kiriko Lynch
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2023
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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