343619036-6-9-2022-53-CC-SMAY-CF8MB7-20220609092727

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343619036
Report Date: 06/09/2022
Date Signed: 06/09/2022 09:27:34 AM

Document Has Been Signed on 06/09/2022 09:27 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:	BLOOMGREN, RACHEL		FACILITY NUMBER:	343619036
ADMINISTRATOR:	BLOOMGREN, RACHEL		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(916) 521-0082
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY:	14	CENSUS: 10	DATE:	06/09/2022
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Rachel Bloomgren		TIME COMPLETED:	09:40 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Salene Mayberry and Christopher Jackson met with Licensee Rachel Bloomgren for the purpose of a case management inspection. The purpose of today's visit is to change Licensee's master bedroom/bathroom to off-limits and to make the bathroom off of the playroom on-limits. Census at the time of inspection was 10 children. Licensee's operating hours are Monday through Thursday from 8:30 am to 11:30 pm, with extended days on Tuesday and Thursday until 2:45 pm. Licensee indicated that she will be closed for the entire month of July. All adults subject to criminal background review have obtained a criminal record clearance. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated. Licensee has requested to make the master bedroom/bathroom off-limits and to make the bathroom off the playroom on-limits. A health and safety inspection was conducted in all areas accessible to children. LPA’s verified hazardous and toxic items were inaccessible to children in care. Licensee stated there are no weapons in the home. The outdoor play space is fenced, and the duck pond on the premises is inaccessible to children in care and currently empty. LPAs observed an in-ground pool that meets Title 22 Regulations and is not used by children in care. LPAs also observed several pets (dogs, cats, chickens, rabbits, sheep, goats and a pony, etc.), Licensee stated that all children are supervised when interacting with the animals in their pens. Report Continued on LIC812-C.

SUPERVISOR'S NAME: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Salene Mayberry	TELEPHONE: 916-263-5744
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: BLOOMGREN, RACHEL	FACILITY NUMBER: 343619036
	VISIT DATE: 06/09/2022

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As of today June 9, 2022, the bathroom off of the playroom will be changed to on-limits area and accessible to children in care. Licensee has requested to make the OFF-LIMIT Areas: the main house, including the master/bathroom, garage, pool and pond. Licensee acknowledges that children may never enter these off-limit areas.

An Exit interview was conducted, and the report was reviewed with the Licensee. LPA Mayberry posted a notice of site visit which Licensee understands must remain posted for 30 days. Licensee acknowledges that a failure to comply with the posting requirements shall result in an immediate civil penalty of $100.

In the areas that were evaluated, no deficiencies were cited during today’s inspection.

SUPERVISOR'S NAME: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Salene Mayberry	TELEPHONE: 916-263-5744
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

LIC809 (FAS) - (06/04)

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