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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343614395
Report Date: 09/30/2022
Date Signed: 09/30/2022 11:44:45 AM


Document Has Been Signed on 09/30/2022 11:44 AM - 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:MISSION AVENUE PRESCHOOLFACILITY NUMBER:
343614395
ADMINISTRATOR:CHRISTINA DIAZ BUSHMANFACILITY TYPE:
830
ADDRESS:2433 MISSION AVENUETELEPHONE:
(916) 487-4647
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:22CENSUS: 8DATE:
09/30/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Christina Diaz BushmanTIME COMPLETED:
12:00 PM
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At 11:00 a.m. on Friday, September 30th, 2022, Licensing Program Analyst (LPA) Karyn Guerra met with Director, Christina Diaz Bushman, for the purpose of a case management inspection. LPA observed a census of 8 infant children supervised by 2 staff. Director stated that the toddler classroom was closed due to staffing. The facility was previously cited on 7/13/2022 regarding personnel requirements. During today's inspection, LPA conducted a file review and observed required documentation. The citation has been corrected per POC and has been cleared.

No regulatory citations were issued during today's inspection. An exit interview was conducted and this report was reviewed with the Director, Christina Diaz Bushman. A notice of site visit was provided and shall remain posted for 30 days.
SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Karyn GuerraTELEPHONE: (916) 216-7790
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2022
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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