<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 554500578
Report Date: 07/11/2023
Date Signed: 07/11/2023 02:05:44 PM

Document Has Been Signed on 07/11/2023 02:05 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
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ATWOOD, SARAH-ANNFACILITY NUMBER:
554500578
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 7DATE:
07/11/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Licensee, Sarah-Ann AtwoodTIME COMPLETED:
02:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 06/07/2023, Licensee self reported an incident that occurred on 06/06/2023 where a child (C1) left the fenced backyard and was found in a neighbor's yard. Licensee has since added measures such as an additional lock on the gate that exits the backyard. Based on an interview with the Licensee, LPA determined that there was an absence of supervision at the time.

A Title 22 deficiency is cited on LIC 809-D. Licensee acknowledges, that for TYPE A DEFICIENCIES ONLY
upon receipt, Licensee shall post LIC 809-D with Type A deficiency for 30 days and provide copies of this
licensing report to parents/guardians of children in care at the facility and to parents/guardians of children
newly enrolled at the facility during the next 12 months. LIC9224 must be signed by parents/guardians and
kept with the children's forms as a receipt whenever any Type A documents are provided by the Licensee.
LIC9224 and Appeal Rights were provided.

The Notice of Site Visit (LIC 9213) was posted where the parent/guardian of children enter and exit the facility. The Notice of Site Visit (LIC 9213) must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

An exit interview was conducted and a Notice of Site Visit posted.
SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Tobias Lake
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2023
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 07/11/2023 02:05 PM - It Cannot Be Edited


Created By: Tobias Lake On 07/11/2023 at 01:41 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ATWOOD, SARAH-ANN
FACILITY NUMBER: 554500578

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/11/2023
Section Cited
CCR
102417(a)

1
2
3
4
5
6
7
102417 Operation of a Family Child Care Home. (a) the licensee shall be present... and shall ensure that children in care are supervised at all times. This requirement was not met by evidenced by:
1
2
3
4
5
6
7
Licensee has added locks to the gate in the backyard and has increased the amount of supervision needed for the child that wondered away.
8
9
10
11
12
13
14
Based on interviews conducted, it was determined C1 wandered away from the facility, and was found in the gated yard of a neightbor. This is an immediate risk to the health, safety, or personal rights to children in care.
8
9
10
11
12
13
14
IMMEDIATE CIVIL PENALTY IN THE AMOUNT OF $500 IS ASSESSED

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Jeanne Smith
LICENSING EVALUATOR NAME:Tobias Lake
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2