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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393604765
Report Date: 03/15/2023
Date Signed: 03/15/2023 01:15:02 PM


Document Has Been Signed on 03/15/2023 01:15 PM - 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:CATALYST KIDS - JACOBSONFACILITY NUMBER:
393604765
ADMINISTRATOR:MASTROPIERRO,MALISSAFACILITY TYPE:
840
ADDRESS:1750 KAVANAGH STREETTELEPHONE:
(209) 832-8799
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:70CENSUS: 0DATE:
03/15/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:13 AM
MET WITH:Andiana SerranoTIME COMPLETED:
11:10 AM
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On March 15, 2023, Licensing Program Analyst (LPA) Stacey Williams met with Program Lead, Andiana Serrano to follow up on the Unusual Incident Report (UIR) submitted to Community Care Licensing on March 14, 2023.

LPA toured the facility and conducted an interview with staff regarding the incident.

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


Facility evaluation report was reviewed and discussed with Program Lead, Andiana Serrano. Exit interview was conducted. A Notice of Site Visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Stacey WilliamsTELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2023
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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