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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313616989
Report Date: 09/28/2023
Date Signed: 09/28/2023 02:47:55 PM


Document Has Been Signed on 09/28/2023 02:47 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:JACOBSON, JOELETTEFACILITY NUMBER:
313616989
ADMINISTRATOR:JACOBSON, JOELETTEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 368-6137
CITY:COLFAXSTATE: CAZIP CODE:
95713
CAPACITY:14CENSUS: 0DATE:
09/28/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Joelette JacobsonTIME COMPLETED:
02:50 PM
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At 2:30pm on 9/28/2023, Licensing Program Analyst (LPA) Matthew Gallo met with licensee Joelette Jacobson for the original purpose of an unannounced annual inspection. Upon arrival, licensee greeted LPA outside and stated that they have not operated their day care since May and have decided to close. Signature on this form acknowledges that license will be forfeit, and licensee will have to submit another application if they would like to provide child care at this location in the future.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Matthew GalloTELEPHONE: (916) 208-3734
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023
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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