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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 310311751
Report Date: 01/23/2025
Date Signed: 01/23/2025 03:13:13 PM

Document Has Been Signed on 01/23/2025 03:13 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 CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ADVENTURE CLUB - KASEBERGFACILITY NUMBER:
310311751
ADMINISTRATOR/
DIRECTOR:		LISA HOGANFACILITY TYPE:
840
ADDRESS:1040 MAIN STTELEPHONE:
(916) 782-8433
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 90TOTAL ENROLLED CHILDREN: 90CENSUS: 44DATE:
01/23/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Sarah Beeson - Site CoordinatorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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An unannounced inspection was conducted today by Licensing Program Analyst Owens. LPA Owens met with Site Coordinator Sarah Beeson.

The purpose of the inspection is to address an unusual incident that was self reported by the facility. The incident occurred on 2/2024 where a child was left unsupervised in the bathroom for approximately 5 minutes. The child was unharmed and was returned to the classroom.

See 809-D for citation.

Notice of site visit and appeal rights were given to site supervisor at time of inspection.



Mai Lor
Katrina Owens
DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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 01/23/2025 03:13 PM - It Cannot Be Edited


Created By: Katrina Owens On 01/23/2025 at 02:52 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: ADVENTURE CLUB - KASEBERG
FACILITY NUMBER: 310311751

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/27/2025
Section Cited

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Responsibility for providing care and supervision:
The licensee shall provide care and supervision as necessary to meet the children's needs. No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
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This requirement was not met as a child was left unsupervised in the bathroom for approximately 5 minutes. This is an immediate risk to a child.
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Deficiency cleared at time of inspection.

Site supervisor was given the LIC9224 and explained at time of inspection.

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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:Mai Lor
TELEPHONE:
LICENSING EVALUATOR NAME:Katrina Owens
TELEPHONE:
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2025


LIC809 (FAS) - (06/04)
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