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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313605150
Report Date: 12/16/2022
Date Signed: 12/16/2022 09:21:48 AM


Document Has Been Signed on 12/16/2022 09:21 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833



FACILITY NAME:KLEBOFSKI, MICHELLEFACILITY NUMBER:
313605150
ADMINISTRATOR:KLEBOFSKI, MICHELLEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 259-4111
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:14CENSUS: 0DATE:
12/16/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Michelle KlebofskiTIME COMPLETED:
09:30 AM
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On Licensing Program Analyst (LPA) Jeremey McClain met with Licensee Michelle Klebofski for an unannounced case management inspection. The initial intent was for LPA to conduct a required annual inspection, however no children were present and Licensee is not currently operating. Licensee was previously on inactive status and stated that she would like to renew inactive status. Licensee completed a Request for Inactive Status (LIC 9211).

This report was reviewed with the licensee and exit interview was conducted. LPA provided a Notice of Site Visit.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Jeremey McClainTELEPHONE: (916) 216-7801
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2022
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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