<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 573621066
Report Date: 04/14/2022
Date Signed: 04/14/2022 01:44:50 PM


Document Has Been Signed on 04/14/2022 01:44 PM - 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:DCCNSFACILITY NUMBER:
573621066
ADMINISTRATOR:ALLEWELT-SMITH, LIZFACILITY TYPE:
850
ADDRESS:412 C STREETTELEPHONE:
(530) 760-8713
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY:30CENSUS: 13DATE:
04/14/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Liz Allewelt-Smith, Executive Director/TeacherTIME COMPLETED:
01:55 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Salene Mayberry and Licensing Program Manager (LPM) Bettina Engelman met with Executive Director/Teacher Liz Allewelt-Smith to follow up on a request to update the facility's address of record. No other changes have been requested.

The facility use to utilize the address of the church office; however, the facility's actual entrance is 477 4th Street. Licensing staff will make this update and will provide the Executive Director with a new license reflecting this change.

The facility evaluation report was reviewed and discussed with the Executive Director. An Exit interview was conducted. LPA posted a notice of site visit which must remain posted 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)
Page: 1 of 1