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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570312670
Report Date: 04/14/2022
Date Signed: 04/14/2022 11:25:37 AM


Document Has Been Signed on 04/14/2022 11:25 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833



FACILITY NAME:CATALYST KIDS - ROBERT E. WILLETTFACILITY NUMBER:
570312670
ADMINISTRATOR:ANGELO, MARISSAFACILITY TYPE:
840
ADDRESS:1207 SYCAMORE LANETELEPHONE:
(530) 758-8342
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY:70CENSUS: 6DATE:
04/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Shannon Kumar, Interim Assistant Site SupervisorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Salene Mayberry and Licensing Program Manager (LPM) Bettina Engelman met with Interim Assistant Site Supervisor, Shannon Kumar to follow up on an Unusual Incident Report (UIR) submitted to Community Care Licensing on 04/6/2022. During today's visit the facility was toured. Six school age children were present during the inspection.

Licensing staff interviewed the Interim Assistant Site Supervisor regarding the incident.

The facility evaluation report was reviewed and discussed with Interim Assistant Site Supervisor. An Exit interview was conducted. A Notice of Site Visit was posted by LPA and must remain up for 30 days. Failure to comply with the posting requirements shall result in an immediate civil penalty of $100.

In the areas that were evaluated, no deficiencies were cited during today's inspection.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Salene MayberryTELEPHONE: 916-263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
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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