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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343615334
Report Date: 10/24/2023
Date Signed: 10/24/2023 10:39:02 AM


Document Has Been Signed on 10/24/2023 10:39 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:4TH R - H. ALLEN HIGHTFACILITY NUMBER:
343615334
ADMINISTRATOR:SANCHEZ-AGUILAR, JOSEPHFACILITY TYPE:
840
ADDRESS:3200 NORTH PARK DRIVETELEPHONE:
(916) 566-6422
CITY:SACRAMENTOSTATE: CAZIP CODE:
95835
CAPACITY:100CENSUS: 0DATE:
10/24/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Latika JainTIME COMPLETED:
11:00 AM
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On October 24, 2023, Licensing Program Analyst (LPA) Amanda Sutter met with Director Latika Jain for a case management inspection to discuss the unusual incident report (UIR) that was reported and submitted on October 13, 2023. No daycare children were present at the facility.

LPA made observations and conducted an interview.

No deficiencies were cited in today’s visit.

Exit interview was conducted with Latika Jain and notice of site visit was posted.
SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Amanda SutterTELEPHONE: (916) 261-8918
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023
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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