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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340310500
Report Date: 08/08/2019
Date Signed: 08/08/2019 12:37:49 PM

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:4TH R - CROCKER RIVERSIDEFACILITY NUMBER:
340310500
ADMINISTRATOR:TREVOR MENSIK/STEAV JORDANFACILITY TYPE:
840
ADDRESS:2970 RIVERSIDE BLVDTELEPHONE:
(916) 264-8385
CITY:SACRAMENTOSTATE: CAZIP CODE:
95818
CAPACITY:100CENSUS: 85DATE:
08/08/2019
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Trevor MensikTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Goodell met with director Trevor Mensik for a Case Management Inspection. Licensee requested a change in capacity from 100 to 150 children enrolled in kindergarten and above. The program is currently operating in portable, and cafeteria, auditorium located at Crocker Riverside Elementary School. During today's inspection, LPA toured areas and observed census of 35 children in the auditorium with 3 staff and 50 children in the outdoor area with 4 staff. All staff present during census obtained fingerprint clearance through community care licensing. Facility submitted a fire clearance issued by the Sacramento Fire Department dated for January 4. 2019.

Indoor Activity Space:
LPA inspected the library located in the portable near the outdoor area to be used as the added space for the increased capacity. LPA observed age appropriate furniture and equipment. Director acknowledged drinking must be available for children both indoors and outdoors.

Outdoor Activity Space:
The program will continue to use the outdoor play area previously approved. Director acknowledged supervision requirements during outdoor play and transitions to playground.

According to Title 22, Division 12, Section 101538.2(c) & 101538.3(c), the school-age program is exempt from the indoor and outdoor square footage as well as the restroom requirements. Therefore, no measurements were taken during inspection.

As of today's inspection, facility is approved for a capacity of 150 children enrolled in kindergarten and above.

Report reviewed with director. Notice of Site Visit issued and must remain posted for 30 days.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Kristal GoodellTELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2019
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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