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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 093614550
Report Date: 06/08/2023
Date Signed: 06/08/2023 02:20:50 PM


Document Has Been Signed on 06/08/2023 02:20 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
RIVER CITY (SACTO)CC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:PINE TOP MONTESSORI SCHOOLFACILITY NUMBER:
093614550
ADMINISTRATOR:JILL KIMEFACILITY TYPE:
850
ADDRESS:6526 PONY EXPRESS TRAILTELEPHONE:
(530) 903-3106
CITY:POLLOCK PINESSTATE: CAZIP CODE:
95726
CAPACITY:30CENSUS: 9DATE:
06/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Jill KimeTIME COMPLETED:
02:40 PM
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On June 8th, 2023, Licensing Program Analyst (LPA) Soleil Marx and Licensing Program Manager (LPM) Natalie Dunaway, met with Director, Jill Kime, for the purpose of conducting a Case Management Inspection. Today's census included nine preschool children in care with one staff and the Director.

Sacramento Regional Office was notified of an unusual incident that occurred on May 31st, 2023 at approximately 10:30AM. It was reported that while in a cross walk during a walking field trip to a community park, there was an accident involving a van that resulted in five children being injured.

During today's inspection, LPA/LPM reviewed records relevant to the incident and interviewed the Director that witnessed the incident.

Based on today’s inspection, no title 22 citations are being issued.

Exit interview was conducted and a copy of this report was given to the Director. Notice of site was given and must remain posted for 30 days. Appeal rights provided.

SUPERVISOR'S NAME: Natalie DunawayTELEPHONE: (916) 584-3508
LICENSING EVALUATOR NAME: Soleil MarxTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2023
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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