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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393605862
Report Date: 10/18/2021
Date Signed: 10/18/2021 01:11:15 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:CATALYST KIDS - JACOBSONFACILITY NUMBER:
393605862
ADMINISTRATOR:MASTROPIERRO,MALISSAFACILITY TYPE:
850
ADDRESS:1750 KAVANAGH STREETTELEPHONE:
(209) 832-8799
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:48CENSUS: 11DATE:
10/18/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:56 AM
MET WITH:Stephanie TIME COMPLETED:
01:00 PM
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On October 18, 2021, Licensing Program Analyst (LPA) Stacey Williams arrived at the facility for the purpose of conducting a case management inspection. LPA met with Facility Representative, Stephanie Trejo. LPA observed (11) eleven children supervised by two staff.

Community Care Licensing received an unusual incident report pertaining to child #1(C1). LPA interviewed staff and reviewed staff and child files during today's inspection.

Further investigation is needed.

Exit interview conducted and notice of site visit was provided and shall remain posted for 30 days.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Stacey WilliamsTELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021
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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