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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317004491
Report Date: 01/23/2025
Date Signed: 01/23/2025 11:06:49 AM

Document Has Been Signed on 01/23/2025 11:06 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ADULT DAY EXPERIENCES (ADE)FACILITY NUMBER:
317004491
ADMINISTRATOR/
DIRECTOR:
ASHLI KACKLEFACILITY TYPE:
775
ADDRESS:2510 WARREN DRIVE, SUITE ATELEPHONE:
(916) 632-2332
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY: 30CENSUS: DATE:
01/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Ashli KackleTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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Licensing Program Analysts Kerry Hiratsuka and Kayla Adkison arrived unannounced for the purpose of conducting an annual/required inspection. The facility appeared clean and in good repair. LPAs were met by Ashli Kackle Administrator, we toured the facility. The LPA reviewed administration records; care and supervision; medication; staff and client records; and the physical plant.

The tour started by walking the entire facility. There are four class rooms, a media room, a cubby room, an arts and crafts area, a locked store room with chemicals, a staff area, a quiet area, a kitchen area, and two hall bathrooms. The students bring in their own food so there is nothing prepared. They can warm up their food.
The Smoke detectors are hard wired. The Fire extinguishers were charged, serviced and functional.

Four staff records were reviewed and found to be current, including first aid and health clearance and training. Four client records were reviewed and they were current, including admission agreement, personal rights, and the physician's report.

Annual facility report reviewed with administrator. No deficiencies cited
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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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