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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343616796
Report Date: 08/12/2021
Date Signed: 08/12/2021 11:49:30 AM

Document Has Been Signed on 08/12/2021 11:49 AM - 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:OUR LADY OF THE ASSUMPTIONFACILITY NUMBER:
343616796
ADMINISTRATOR:DUESBURY, ANN MARIEFACILITY TYPE:
850
ADDRESS:5055 COTTAGE WAYTELEPHONE:
(916) 485-1504
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 30TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
08/12/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Ann Marie DuesburyTIME COMPLETED:
10:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Gagandeep Singh met with the director, Ann Marie Duesbury, to deliver the complaint findings. During the investigation, it was found that there was an incident of a child leaving the classroom unattended. During record review, it was found that the facility did not reported the incident to the Department. LPA discussed the reporting requirements and explained that the incident must have been reported. The director understands the requirements and agreed to follow.

See next page for deficiencies cited today. Copy of this report is reviewed and provide to the director.

SUPERVISORS NAME: Maria Mayorga
LICENSING EVALUATOR NAME: Gagandeep Singh
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2021
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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Document Has Been Signed on 08/12/2021 11:49 AM - It Cannot Be Edited


Created By: Gagandeep Singh On 08/12/2021 at 10:28 AM
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: OUR LADY OF THE ASSUMPTION
FACILITY NUMBER: 343616796

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/27/2021
Section Cited
CCR
101212(d)(1)(C)

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Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing
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The director agreed to submit the written report to the Department before August 27, 2021.
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 the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event. Events reported shall include the following: Any unusual incident or child absence that threatens the physical or emotional health or safety of any child. This requirement is not met as evidenced by interviews it was found that there was a child left the classroom unattended and the facility did not report to the Department. This poses a potential Health and Safety risk to children in care
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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:Maria Mayorga
LICENSING EVALUATOR NAME:Gagandeep Singh
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2021


LIC809 (FAS) - (06/04)
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