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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340321380
Report Date: 01/19/2023
Date Signed: 01/19/2023 11:28:04 AM


Document Has Been Signed on 01/19/2023 11:28 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:PETER BURNETT PRESCHOOLFACILITY NUMBER:
340321380
ADMINISTRATOR:MAI VANGFACILITY TYPE:
850
ADDRESS:6032 36TH AVE. RM.#3TELEPHONE:
(916) 277-6522
CITY:SACRAMENTOSTATE: CAZIP CODE:
95824
CAPACITY:24CENSUS: 18DATE:
01/19/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Gulalai ShetabTIME COMPLETED:
12:00 PM
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On January 19, 2023, Licensing Program Analysts (LPAs) Amanda Sutter and Amanda Blesi met with lead teacher Gulalai Shetab for the purpose of a plan of correction inspection. Upon arrival, LPAs observed 18 children supervised by 5 staff.

LPAs cleared the citation 101217(a) for incomplete staff files issued on the date 11/29/2022. LPAs observed all staff files to be complete.

LPAs reviewed this report with Staff Gulalai Shetab. Staff was provided with a notice of site visit that must be posted for 30 days
SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Amanda SutterTELEPHONE: (916) 261-8918
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2023
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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