<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343614545
Report Date: 11/21/2022
Date Signed: 11/21/2022 10:51:16 AM

Document Has Been Signed on 11/21/2022 10:51 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:SHALOM PRESCHOOLFACILITY NUMBER:
343614545
ADMINISTRATOR:STACEY WORTHENFACILITY TYPE:
850
ADDRESS:2320 SIERRA BLVD.TELEPHONE:
(916) 485-4151
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY: 173TOTAL ENROLLED CHILDREN: 173CENSUS: 77DATE:
11/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Stacey WorthenTIME COMPLETED:
11:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On November 21, 2022 at approximately 10:00 AM Licensing Program Analyst (LPA) Josiah Gathing met with Director Stacey Worthen and Head of School Jilian Bar-Or for an unannounced Case Management Inspection regarding an Immediate Exclusion Notice for Miguel Hernandez.. LPA and Director toured the facilities and observed 77 children being supervised by 22 staff. All individuals subject to criminal record review have been cleared.

Based on evidence obtained during today's visit, LPA has verified Miguel Hernandez is not present, employed, or residing at the facility. Director and Head of School stated that the individual has been disassociated from employment and will not be returning. LPA requested a written document stating the individual has been removed from the school.

No deficiencies cited during inspection. Report reviewed and discussed with Director. Notice of Site Visit issued and must remain posted for 30 days.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Josiah Gathing
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1