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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623957
Report Date: 12/13/2021
Date Signed: 12/13/2021 11:13:41 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:SHANNON, ERIKAFACILITY NUMBER:
343623957
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 3DATE:
12/13/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Erika ShannonTIME COMPLETED:
11:30 AM
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Licensing program Analyst (LPA) Christopher Bello arrived at the facility at approximately 9:30am and met with licensee Erika Shannon for the purpose of a capacity increase from 8 to 14 children. LPA Bello toured all areas of the home that are accessible to children, today’s census included three children including licensee’s minor child. Also present during today’s inspection was licensee’s minor child’s father who has been fingerprint cleared through Community Care Licensing.

Off-limit areas include: Entire upstairs, garage, kitchen and pantry. Licensee acknowledged that children may never enter these off-limit areas.

LPA observed a current roster of the enrolled children and fire drill log. The Fire Safety Inspection Clearance has been received and granted on 12/8/21.

Licensee acknowledges that when there is no assistant present, facility will revert back to the small capacity. Licensee acknowledges that children residing in the home under the age of 10 years shall be included in capacity.
LPA consulted with licensee regarding the use of Guardian. LPA consulted with licensee regarding Safe Sleep and provided printed regulations.

In the areas that were evaluated, no deficiencies were observed at the time of the visit.

Effective today, 12/13/21, LPA is granting a license to serve 12 children (when there is an assistant present) with no more than 4 infants or capacity of 14 children when 1 child in kindergarten or elementary school and 1 child at least age 6 and a maximum of 3 infants. Infants are children under the age of 2 years old. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Christopher BelloTELEPHONE: (916) 862-0844
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
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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