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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 093623346
Report Date: 01/20/2023
Date Signed: 01/20/2023 10:06:00 AM


Document Has Been Signed on 01/20/2023 10:06 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
RIVER CITY (SACTO)CC, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833



FACILITY NAME:ALL STAR GYMNASTICSFACILITY NUMBER:
093623346
ADMINISTRATOR:BEBOUT, DOMINIQUE(NIKI)FACILITY TYPE:
850
ADDRESS:6160 ENTERPRISE DR SUITE ATELEPHONE:
(530) 622-7684
CITY:DIAMOND SPRINGSSTATE: CAZIP CODE:
95619
CAPACITY:12CENSUS: 6DATE:
01/20/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Dominique BeboutTIME COMPLETED:
10:30 AM
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Licensing Program Analysts (LPAs) Soleil Marx and Amanda Sutter met with Director Dominique Bebout for the purpose of an unannounced plan of correction inspection. LPAs observed a census of 6 children supervised by one staff.

LPA observed the facility was within their capacity of their license of 12, with 6 children in care. LPA will clear deficiency CCR 101161(a) that was cited on 12/20/2022.

LPA observed mandated reporter training was completed by staff by viewing current certificates on file. LPA will clear deficiency HSC 1596.8662(b)(1) that was cited on 12/20/2022.

LPA observed completed staff files that contained required documentation. LPA will clear deficiency CCR 101217(a) that was cited on 12/20/2022.LPA provided Director with LIC 125 for reference on maintaining files moving forward.

Report was reviewed with Director Dominique Debout and exit interview was conducted. A notice of site visit was given and must remain posted for 30 days.


SUPERVISOR'S NAME: Natalie DunawayTELEPHONE: (916) 584-3508
LICENSING EVALUATOR NAME: Soleil MarxTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023
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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