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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343620058
Report Date: 10/23/2019
Date Signed: 10/23/2019 12:01:57 PM

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:CARL SUNDAHL ELEMENTARY SCHOOL-MONTESSORI PROGRAMFACILITY NUMBER:
343620058
ADMINISTRATOR:HIMMRICH, MONIKAFACILITY TYPE:
850
ADDRESS:9932 INWOOD ROADTELEPHONE:
(916) 294-2425
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:25CENSUS: 23DATE:
10/23/2019
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Monika HimmrichTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Kelly Ferrara met with Director Monika Himmrich for a Plan of Correction inspection to verify correction of the deficiency that was cited on September 18th, 2019 with a due date of October 18th, 2019. At the time of the inspection, there were 23 children present being supervised by two staff.

LPA conducted a children's file review by taking a random sample of children currently enrolled. LPA observed that each child had the Parent's Report (LIC702) and completed Physician's Report (LIC701) in their file

LPA was able to clear the deficiency previously cited and provided a letter to the Director as proof.

No additional citations were issued based on today's inspection. An exit interview was conducted and a Notice of Site visit was provided and posted.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Kelly FerraraTELEPHONE: (916) 425-5932
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2019
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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