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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005272
Report Date: 01/25/2024
Date Signed: 01/25/2024 11:21:21 AM

Document Has Been Signed on 01/25/2024 11:21 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 TOOFACILITY NUMBER:
317005272
ADMINISTRATOR:ASHLI E. KACKLEFACILITY TYPE:
775
ADDRESS:2520 WARREN DRIVE, STE BTELEPHONE:
(916) 251-7250
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY: 30CENSUS: 24DATE:
01/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Ashli KackleTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Thursday January 25, 2024 to conduct the unannounced annual inspection.

LPA met with Administrator Ashli and explained the purpose of the visit.

During today's visit, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed 8 participant files and 5 staff files. All files contained the required paperwork.

LPA and Administrator toured facility together to ensure the health and safety of participants in care. Areas toured included classrooms, bathrooms, kitchen, and staff break room. In the areas toured no immediate health, safety, or personal rights violations were observed. Facility is current on fire drills. First Aid kit was fully stocked. Chemicals were kept locked an inaccessible to clients. Facility has PPE and covid tests on site.

Administrator will email LPA an updated LIC500 and a copy of 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: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2024
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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