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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 573615400
Report Date: 03/22/2023
Date Signed: 03/22/2023 09:40:45 AM


Document Has Been Signed on 03/22/2023 09:40 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:YCOE ALYCE NORMAN HSFACILITY NUMBER:
573615400
ADMINISTRATOR:JACQUELINE TAMFACILITY TYPE:
850
ADDRESS:1200 ANNA STREETTELEPHONE:
(916) 375-7650
CITY:WEST SACRAMENTOSTATE: CAZIP CODE:
95605
CAPACITY:144CENSUS: 16DATE:
03/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Site Coordinator, Jacqueline TamTIME COMPLETED:
09:45 AM
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Licensing Program Analysts (LPAs) Lauren Scott and Mariya Melnichuk met with Site Coordinator, Jacqueline Tam to follow up on an Unusual Incident Report (UIR) that was reported to Community Care Licensing on 03/21/2023. During today's visit the facility was toured. Present in the classroom, where the incident occurred, were 16 children and 3 staff.

LPAs interviewed the staff who were present during the incident. LPAs reviewed and discussed this report with Site Coordinator, Jacqueline Tam. LPAs observed the classroom and location where the incident occurred.

The facility reported the UIR to Community Care Licensing within 24 hours. Facility was reminded to submit the physical UIR within 7 days.

Facility evaluation report was reviewed and discussed with Site Coordinator, Jacqueline Tam. 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.

In the areas that were evaluated, no deficiencies were cited during today's inspection.
SUPERVISOR'S NAME: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR NAME: Lauren ScottTELEPHONE: (916) 926-9488
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2023
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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