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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340314892
Report Date: 10/02/2024
Date Signed: 10/02/2024 03:09:46 PM


Document Has Been Signed on 10/02/2024 03:09 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:GENERAL DAVIE, JR. PRIMARY CENTERFACILITY NUMBER:
340314892
ADMINISTRATOR:LEWIS, TIFFANYFACILITY TYPE:
850
ADDRESS:1500 DOM WAYTELEPHONE:
(916) 971-7375
CITY:SACRAMENTOSTATE: CAZIP CODE:
95864
CAPACITY:296CENSUS: 0DATE:
10/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Isabelle McDanielTIME COMPLETED:
03:15 PM
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On October 2nd, 2024 Licensing Program Analysts (LPAs) Mandie Goodwin and Kyrsten Williams met with facility representative Isabelle McDaniel for the purpose of a case management inspection. Upon arrival there were no childen present. Facility self reported an injury that occurred to a child on 9/16/24. During inspection LPAs interviewed staff members that were present when injury occurred and made observations to the playground where the incident happened. Based on todays inspection there was not determined to be a lack of supervision or any physical plant issues on the playground.

Exit interview was conducted with facility representative and a notice of site visit was provided. Notice of site visit must be posted for 30 days. No deficiencies were cited based on todays inspection.
SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Mandie GoodwinTELEPHONE: (916) 639-2867
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2024
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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