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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343619036
Report Date: 03/20/2024
Date Signed: 03/20/2024 09:58:04 AM


Document Has Been Signed on 03/20/2024 09:58 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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:BLOOMGREN, RACHELFACILITY NUMBER:
343619036
ADMINISTRATOR:BLOOMGREN, RACHELFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 521-0082
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:14CENSUS: 12DATE:
03/20/2024
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rachel BloomgrenTIME COMPLETED:
10:15 AM
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On 3/20/2024, Licensing Program Analyst (LPA) Jennie Tedlos conducted an unannouncedCase Management Inspection for the purpose of making an off-limit area at the facility on-limits. LPA met with Licensee Rachel Bloomgren. LPA observed 12 children supervised by the Licensee and her two Assistants.

LPA and Licensee toured the facility. LPA was shown the covered art area that the Licensee is requesting to be on limits. The area has a metal shade structure with an art area and gated sand pit, a small play house, and garden beds. Fencing meets regulation and the gate latches at the top. Licensee states that the whole class will either all be in the area or all be in the yard area for supervision reasons. Current off limit areas of the facility will now be: the main house, the garage, the pool and pond areas, and the pasture.


In the areas that were evaluated today, no deficiencies were observed. An exit interview was conducted and Notice of Site Visit was posted by LPA and must remain posted for 30 days. A failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISOR'S NAME: Karyn GuerraTELEPHONE: (916) 216-7790
LICENSING EVALUATOR NAME: Jennie TedlosTELEPHONE: (916) 936-7763
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024
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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