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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393610611
Report Date: 03/30/2023
Date Signed: 03/31/2023 10:01:04 AM


Document Has Been Signed on 03/31/2023 10:01 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 SOUTH, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833



FACILITY NAME:THOMAS, JACQUELINE & TERRYFACILITY NUMBER:
393610611
ADMINISTRATOR:THOMAS, JACQUELINE & TERRYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 835-7801
CITY:TRACYSTATE: CAZIP CODE:
95377
CAPACITY:14CENSUS: 6DATE:
03/30/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Jacqueline & Terry ThomasTIME COMPLETED:
11:45 AM
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On 3/30/23, Licensing Program Analyst (LPA) Corina Beckby met with the Licensees’, Jacqueline and Terry Thomas for the purpose of a case management visit to sign a Confirmation of Removal Notice, dated March 19, 2020. LPA observed Licensee, Co-Licensee and assistants caring for 6 of children.

Licensee stated said person never worked at the facility after she was told by previous LPA that said person could not be hired. Co-Licensee, Terry Thomas, signed the document and kept a copy for their records.

An Exit interview was conducted, and the report was reviewed and provided to Licensee. LPA discussed and provided Appeal Rights to Licensee. LPA posted the Notice of Site Visit and Licensee acknowledges it must remain posted for 30 days. A Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
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SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Corina BeckbyTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023
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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