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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480111107
Report Date: 05/08/2023
Date Signed: 05/08/2023 11:07:54 AM

Document Has Been Signed on 05/08/2023 11:07 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
CHICO-DAY CARE, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:MOTHER'S DAY OUT-INFANT CENTERFACILITY NUMBER:
480111107
ADMINISTRATOR:SALM-JACOBS, MARGARETFACILITY TYPE:
830
ADDRESS:425 HEMLOCKTELEPHONE:
(707) 448-5159
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 16TOTAL ENROLLED CHILDREN: 16CENSUS: DATE:
05/08/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Kelly JacobsTIME COMPLETED:
10:55 AM
NARRATIVE
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On 5/8/2023 at 10:35 AM, Licensing Program Analyst (LPA) J. Helton made a case management inspection and met with facility representative Kelly Jacobs. The inspection was made in response to water lead testing samples not being completed by January 1, 2023.

The following 2 deficiency are being cited (see LIC 809D). A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the facility representative Kelly Jacobs ..
SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Jackie Helton
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2023
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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Document Has Been Signed on 05/08/2023 10:53 AM - It Cannot Be Edited


Created By: Jackie Helton On 05/08/2023 at 10:45 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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: MOTHER'S DAY OUT-INFANT CENTER
FACILITY NUMBER: 480111107

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2023
Section Cited
HSC
1596.76

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(a)(1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contaminiation levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the intial test.
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Director will either submit a waiver request, or complete the elad testing and provide all documentation to LPA
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This requirement was not met as evidenced by:
Lead testing samples have not been completed, nor has the waiver request been received.
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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:Erin Virrueta
LICENSING EVALUATOR NAME:Jackie Helton
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2023


LIC809 (FAS) - (06/04)
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