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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340309428
Report Date: 06/27/2022
Date Signed: 06/27/2022 03:36:42 PM

Document Has Been Signed on 06/27/2022 03:36 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:SALVATION ARMY DAY CARE CENTERFACILITY NUMBER:
340309428
ADMINISTRATOR:LEONEL GUTIERREZFACILITY TYPE:
850
ADDRESS:2540 ALHAMBRA BLVDTELEPHONE:
(916) 469-4630
CITY:SACRAMENTOSTATE: CAZIP CODE:
95817
CAPACITY: 72TOTAL ENROLLED CHILDREN: 72CENSUS: 20DATE:
06/27/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Leonel GutierrezTIME COMPLETED:
03:45 PM
NARRATIVE
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On Monday, June 27, 2022 at approximately 1:10 PM, Licensing Program Analyst (LPA) Josiah Gathing and Licensing Program Manager (LPM) Seychelle De Luca met with Director, Leonel Gutierrez.

During today's inspection LPM requested a facility roster. Director provided documentation showing information for current children in care. However, the information required for a facility roster was not complete.

Facility is cited a Type B citation. Appeal rights were provided. A notice of site visit was provided and shall remain posted for 30 days.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Josiah Gathing
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2022
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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Document Has Been Signed on 06/27/2022 03:36 PM - It Cannot Be Edited


Created By: Josiah Gathing On 06/27/2022 at 02:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: SALVATION ARMY DAY CARE CENTER
FACILITY NUMBER: 340309428

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/15/2022
Section Cited
HSC
1596.841

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1596.841 Current roster...Facility shall maintain... roster of children... Shall include... name, address... telephone number of the child's parent... name and telephone number of the child's physician.
This requirement was not met as evidenced by:
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Director will provide LPA with a roster showing all children in care since January 2022. LPA printed LIC 9040 to provide to the Director.
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Director stated he was unaware of the requirement to keep the necessary information for a childrens roster for three years.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Seychelle De Luca
LICENSING EVALUATOR NAME:Josiah Gathing
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2022


LIC809 (FAS) - (06/04)
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