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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343601750
Report Date: 10/03/2024
Date Signed: 10/03/2024 11:59:47 AM

Document Has Been Signed on 10/03/2024 11:59 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 CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CHARLES E. MACK PRESCHOOLFACILITY NUMBER:
343601750
ADMINISTRATOR/
DIRECTOR:		COLLIER, ROBERTAFACILITY TYPE:
850
ADDRESS:4701 BROOKFIELD DRIVETELEPHONE:
(916) 422-1566
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 19DATE:
10/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Cheng VangTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Gagandeep Singh met with the facility representative, Cheng Vang, for a case management inspection related to an incident. The facility self reported that on September 30, 2024, a child fell, got hurt and was taken to hospital. Upon LPA’s arrival, there were 19 children in care with two staff members.

During today’s inspection, LPA inspected the classroom and interviewed the staff. During inspection, it was found that a child was playing in reading area of the classroom and tripped on the floor rug, which cause the child to loose the balance. LPA inspected the reading area and did not observe any hazard. Facility representative stated that there were two staff members present at the time of the incident and helped the child. It was found that the child was seen by school nurse and then was taken to the hospital. Per facility representative, the child received stiches and was returned in care yesterday (October 02, 2024). Per facility representative, child's parents were informed in timely manner.

No violation of any regulations was observed. Copy of this report was reviewed and provided to the facility representative. Notice of site visit is posted and shall remain posted for next 30 days.

SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Gagandeep Singh
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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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