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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340318378
Report Date: 10/02/2019
Date Signed: 10/02/2019 09:54:46 AM

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:WILLIAMSON ELEMENTARY SCHOOLFACILITY NUMBER:
340318378
ADMINISTRATOR:MEREDITH, KERILYNFACILITY TYPE:
850
ADDRESS:2276 BENITA DRIVETELEPHONE:
(916) 635-3369
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY:24CENSUS: 21DATE:
10/02/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Christina BrownTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA), Jan Hoshida, met with Lead Teacher, Christina Brown, for a case management visit on this date to discuss the unusual incident report (UIR) that the program submitted on 10/1/19. LPA observed 21 children with four staff present.

LPA conducted interview and observed care and supervision of children in care.

No deficiencies were cited in today’s visit.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Jan HoshidaTELEPHONE: (916) 917-6572
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2019
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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