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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 310311751
Report Date: 01/13/2022
Date Signed: 01/13/2022 09:34:18 AM

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:ADVENTURE CLUB - KASEBERGFACILITY NUMBER:
310311751
ADMINISTRATOR:LISA HOGANFACILITY TYPE:
840
ADDRESS:1040 MAIN STTELEPHONE:
(916) 782-8433
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:90CENSUS: 11DATE:
01/13/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
07:45 AM
MET WITH:Jennifer Ludwig - CCPATIME COMPLETED:
09:45 AM
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An unannounced case management inspection was conducted today by Licensing Program Analyst Owens. LPA Owens met with Child Care Program Assistant, Jennifer Ludwig. Present at time of inspection were three staff and 11 school-age children.

The purpose of the inspection was to conduct interviews and discuss an unusual incident report that was reported to Community Care Licensing.

No deficiencies.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Katrina OwensTELEPHONE: 916-263-6280
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022
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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