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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340310500
Report Date: 12/06/2023
Date Signed: 12/06/2023 02:42:15 PM


Document Has Been Signed on 12/06/2023 02:42 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:4TH R - CROCKER RIVERSIDEFACILITY NUMBER:
340310500
ADMINISTRATOR:DEEANN ESCALANTEFACILITY TYPE:
840
ADDRESS:2970 RIVERSIDE BLVDTELEPHONE:
(916) 264-8385
CITY:SACRAMENTOSTATE: CAZIP CODE:
95818
CAPACITY:150CENSUS: 18DATE:
12/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Amy BrownTIME COMPLETED:
03:15 PM
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On December 6th, 2023, Licensing Program Analysts (LPA) Pa Dao Vang and Mandie Goodwin met with Director Amy Brown to conduct an unannounced Case Management Inspection regarding an Unusual Incident Reported. LPA observed 18 children supervised by 4 adults.

On November 30th, 2023 an Unusual Incident Report was received detailing an incident that occurred on the same day regarding a child's injury outside in the cement area. Director stated that two children (C1 and C2) ran into each other on the cement area, while a teacher was doing an announcement with all the children and staff outside. A staff member was near by and attended to the incident immediately. The child's mother was called and notified about the incident. The parent was 5 minutes away and picked up the child for medical treatment. It was found that the child had a proximal tibia fracture in the right leg.

During the inspection LPAs conducted interview and made observations of the area. LPA did not observed any uneven pavement or objects in the cement area. There was not found to be a lack of supervision.

No deficiencies were cited in today’s visit.

This report was reviewed with Director Amy Brown. LPA provided a Notice of Site Visit, which must remain posted for 30 days.
SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Dao VangTELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023
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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