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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343615334
Report Date: 11/13/2019
Date Signed: 11/13/2019 11:51:32 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:4TH R - H. ALLEN HIGHTFACILITY NUMBER:
343615334
ADMINISTRATOR:WINSCOTT, JENNIFERFACILITY TYPE:
840
ADDRESS:3200 NORTH PARK DRIVETELEPHONE:
(916) 566-6422
CITY:SACRAMENTOSTATE: CAZIP CODE:
95835
CAPACITY:100CENSUS: 0DATE:
11/13/2019
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Mary ChewTIME COMPLETED:
11:50 AM
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Licensing Program Analysts (LPAs) Seychelle De Luca and Fabiola Diaz met with Program Developer Mary Chew for a proof of correction inspection to verify correction for the deficiency that was cited on 10/2/2019. There were no school-age children present during today's inspection. During today's inspection, LPAs reviewed 10 staff files and observed there are there are four fully qualified staff and six aides. LPAs reminded Program Developer to create staff schedules with qualifications in mind.

A copy of the POC letters were provided to Program Developer. No deficiencies were cited during today's inspection. A Notice of Site of Visit was provided and an exit interview was conducted.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Seychelle De LucaTELEPHONE: (916) 217-4316
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2019
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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