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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313610189
Report Date: 09/24/2021
Date Signed: 09/24/2021 01:02:02 PM

Document Has Been Signed on 09/24/2021 01:02 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:ADVENTURE CLUB - BLUE OAKSFACILITY NUMBER:
313610189
ADMINISTRATOR:FLORES, EVILAFACILITY TYPE:
840
ADDRESS:8150 HORNCASTLE AVETELEPHONE:
(916) 771-4859
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 90TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
09/24/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Evila Flores - Child Care Program LeaderTIME COMPLETED:
01:15 PM
NARRATIVE
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An unannounced case management inspection is conducted today by Licensing Program Analyst Owens. LPA Owens met with Evila Flores, Child Care Program Leader. No children were present during the inspection.

The purpose of the inspection is to address an unusual incident that occurred on August 25, 2021 and self reported by the facility.

See deficiency on 809-D.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Katrina Owens
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 09/24/2021 01:02 PM - It Cannot Be Edited


Created By: Katrina Owens On 09/24/2021 at 12:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: ADVENTURE CLUB - BLUE OAKS
FACILITY NUMBER: 313610189

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/24/2021
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision
No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
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Child Care Program Leader, Evila Flores stated child parents were notified of incident. All staff was retrained and reminded about proper supervision and headcount procedures.
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This requirement is not met as evidence by the facility self reported that staff left a child unsupervised waiting by the locked outside gate during transition. This is an immediate risk to a child.
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LPA gave and discussed LIC9224 form to Evila Flores at time of inspection.
Deficiency cleared at time of inspection.

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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:Keven Peters
LICENSING EVALUATOR NAME:Katrina Owens
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2021


LIC809 (FAS) - (06/04)
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