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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343619036
Report Date: 12/03/2021
Date Signed: 12/03/2021 09:08:15 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:BLOOMGREN, RACHELFACILITY NUMBER:
343619036
ADMINISTRATOR:BLOOMGREN, RACHELFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 521-0082
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:14CENSUS: 10DATE:
12/03/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Rachel BloomgrenTIME COMPLETED:
09:15 AM
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On 12/3/2021 at 8:40 AM Licensing Program Analyst (LPA) Jeevun Birk-Miller conducted an unannounced case management inspection and met with Licensee, Rachel Bloomgren. The purpose of the inspection was to make the master bedroom and bathroom on-limits. Licensee has also requested to make the restroom near the preschool room to be placed off-limits. LPA conducted a health and safety inspection of the areas and will be making the changes effective today.

At this no citations were given and an exit interview was conducted. A Notice of Site Visit was given and posted. This shall be posted for 30 days.
SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Jeevun BirkTELEPHONE: (916) 917-6078
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
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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