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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343610146
Report Date: 12/09/2021
Date Signed: 12/09/2021 02:55:49 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:4TH R - WITTER RANCHFACILITY NUMBER:
343610146
ADMINISTRATOR:COOPER, SHANNONFACILITY TYPE:
840
ADDRESS:3790 POPPY HILL WAYTELEPHONE:
(916) 566-1559
CITY:SACRAMENTOSTATE: CAZIP CODE:
95834
CAPACITY:130CENSUS: 12DATE:
12/09/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Shannon CooperTIME COMPLETED:
03:05 PM
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On 12/09/21, Licensing Program Analyst (LPA) Jan Hoshida met with Program Coordinator Shannon Cooper for a case management inspection on this date to discuss the unusual incident report (UIR) that the program submitted on 11/18/2021. Upon arrival, LPA observed 12 day care children supervised by three staff.

LPA conducted additional interviews. No deficiencies were cited in today’s visit.

Exit interview and notice of site visit was posted.
SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Jan HoshidaTELEPHONE: (916) 917-6572
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
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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