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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340320736
Report Date: 07/23/2021
Date Signed: 08/19/2021 12:49:14 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:POPPY PATCH-PHASE IIFACILITY NUMBER:
340320736
ADMINISTRATOR:DOROTHEA JACKSONFACILITY TYPE:
850
ADDRESS:9645 BUTTERFIELDTELEPHONE:
(916) 845-6033
CITY:SACRAMENTOSTATE: CAZIP CODE:
95827
CAPACITY:60CENSUS: 13DATE:
07/23/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Lea CabadingTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Christopher Bello and Mai Lor arrived at the facility to conduct a unannounced Case Management inspection. During the inspection LPAs' observed that Kleenex Tissue paper was substituted as toilet paper. LPAs did not observe any toilet paper in the bathrooms or in the facility. This is considered as potential risk to the children in care. Director stated that she notified the teachers to let her know if they needed anything and that she did not know they were out of toilet paper. Title 22 deficiencies are cited on the subsequent page of this report. Appeal Rights were provided and an exit interview was conducted. A Notice of Site Visit was posted and must remain posted for 30 days.

**AMENDED REPORT**
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Christopher BelloTELEPHONE: (916) 862-0844
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: POPPY PATCH-PHASE II
FACILITY NUMBER: 340320736
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/06/2021
Section Cited

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The licensee shall provide linens of various kinds as necessary to meet the program of services offered by the center and the requirements specified in this chapter. This requirement has not been met by evidence: LPAs observed tissue paper being used as toilet paper. This is considered as an
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potential risk to the children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Christopher BelloTELEPHONE: (916) 862-0844
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2