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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408734
Report Date: 10/26/2021
Date Signed: 10/26/2021 02:02:42 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:MARSHALL LANE PRESCHOOLFACILITY NUMBER:
434408734
ADMINISTRATOR:HEATHER ELSTONFACILITY TYPE:
850
ADDRESS:14114 MARILYN LANETELEPHONE:
(408) 364-4259
CITY:SARATOGASTATE: CAZIP CODE:
95070
CAPACITY:48CENSUS: 20DATE:
10/26/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Schadonna JacksonTIME COMPLETED:
02:00 PM
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LPA Pete Hernandez met with Schadonna Jackson, Director, for an unannounced Case Management - Incident inspection. The purpose of the inspection is to review an unusual incident report, UIR, that was self reported on 10/14/2021. This incident involved C1 and a potential lack of supervision on 10/13/2021. There was one injury resulting from this incident.

LPA inspected the physical plant. LPA interviewed staff. LPA also reviewed incident report, staff files, After conducting an investigation, interviewing staff and parents there is no basis to believe there was any potential lack of supervision on 10/13/2021.

A deficiency is NOT being cited based on the LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, An exit interview was conducted with the licensee. A copy of this report was discussed and left with the Licensee, Schadonna Jackson , whose signature on this form confirm receipt of these documents.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 334-2151
LICENSING EVALUATOR NAME: Pietro HernandezTELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021
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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