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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317004491
Report Date: 12/18/2023
Date Signed: 12/18/2023 02:45:52 PM

Document Has Been Signed on 12/18/2023 02:45 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ADULT DAY EXPERIENCES (ADE)FACILITY NUMBER:
317004491
ADMINISTRATOR:ASHLI KACKLEFACILITY TYPE:
775
ADDRESS:2510 WARREN DRIVE, SUITE ATELEPHONE:
(916) 632-2332
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY: 30CENSUS: 18DATE:
12/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Adriene Gaudet and Suzanne BaskervilleTIME COMPLETED:
03:15 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) Melissa Parks arrived on Monday December 18, 2023 to conduct the unannounced annual inspection.

LPA met with Administrator Suzanne and Licensee Adriene.

During today's visit, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed 10 participant files and 5 staff files. All files contained the required paperwork.

LPA and Licensee toured facility together to ensure the health and safety of participants in care. Areas toured included classrooms, bathrooms, media room, kitchen, and staff breakroom. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA obtained an updated LIC500. Licensee will email LPA the current surety bond.

No deficiencies cited. Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2023
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