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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340318296
Report Date: 02/08/2023
Date Signed: 02/08/2023 12:35:05 PM

Document Has Been Signed on 02/08/2023 12:35 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:HAGGINWOOD STATE PRESCHOOLFACILITY NUMBER:
340318296
ADMINISTRATOR:SYMON, TANISHAFACILITY TYPE:
850
ADDRESS:1418 PALO VERDE AVENUE, RM. 20TELEPHONE:
(916) 566-3475
CITY:SACRAMENTOSTATE: CAZIP CODE:
95815
CAPACITY: 22TOTAL ENROLLED CHILDREN: 22CENSUS: 0DATE:
02/08/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Symon, TanishaTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Alize Tillery conducted an unannounced visit to address a deficiency that was cited during a case management visit on 01/17/2023. Upon arrival, there were no day care children present. During today's inspection, LPA was assisted by Director Tanisha Symon.

On 1/17/2023, the program was cited for having a lead exceedance in water outlets L and J.
Today, LPA was informed that the water outlets have since been replaced and retested. LPA spoke with the company and confirmed that this was completed.

LPA is clearing citation, 101700.3(b)(1).

During todays inspection, no deficiencies were observed.

LPA provided Director a notice of site visit which should remain posted for 30 days.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Alize Tillery
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2023
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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