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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313619586
Report Date: 05/09/2022
Date Signed: 05/09/2022 11:25:40 AM

Document Has Been Signed on 05/09/2022 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:MERRYHILL SCHOOL - FOOTHILLSFACILITY NUMBER:
313619586
ADMINISTRATOR:MOENNING, MELISSAFACILITY TYPE:
850
ADDRESS:3989 FOOTHILLS BLVD.TELEPHONE:
(916) 782-2500
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 104TOTAL ENROLLED CHILDREN: 104CENSUS: 97DATE:
05/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Melissa Moenning - DirectorTIME COMPLETED:
11:30 AM
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An unannounced case management inspection was conducted today by Licensing Program Analyst Owens. LPA Owens met with Director, Melissa Moenning.

The purpose of the inspection is to confirm the confirmation of removal for Maria Antonakis. LPA Owens confirm Ms. Maria Antonakis does not work at the facility and was not present at the facility at time of inspection. Director did submit the completed LIC 300 B form (removal confirmation - Denial) to licensing within the required time frame.


No deficiencies
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Katrina Owens
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2022
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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