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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340310500
Report Date: 11/21/2019
Date Signed: 11/21/2019 01:00:36 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:150CENSUS: 20DATE:
11/21/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Deeann EscalanteTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Goodell met with site director Deeann Escalante for an unannounced Annual Inspection. During inspection LPA observed 20 children present with two staff. All individuals present have obtained fingerprint clearance through Community Care Licensing. Facility's hours of operation are Monday- Friday, 7am-6pm. The after school program operates in auditorium, portable, library, and cafeteria at the Crocker Riverside Elementary School.

LPA toured the facility including all activity/classroom areas, food service area, and restrooms. LPA observed fire extinguisher 3A40BC, smoke and carbon monoxide detectors. LPA observed the outdoor play area and play equipment. Drinking water is made readily available for children both indoor and outdoor. LPA observed sign/in-sign/out sheets, fire drill log and children roster. LPA reviewed children and staff files. At least one staff member present today has current CPR/ First Aid that expires on 1/10/2020.
No Title 22 Deficiencies cited. LPA reviewed report with the director and provided copies. An exist interview was conducted. 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: 11/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2019
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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