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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
343617215
Report Date:
09/14/2022
Date Signed:
09/19/2022 03:30:08 PM
Document Has Been Signed on
09/19/2022 03:30 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:
KELLI'S PALS PRESCHOOL & DAY CARE
FACILITY NUMBER:
343617215
ADMINISTRATOR:
BOYD, LIN
FACILITY TYPE:
850
ADDRESS:
501 SAN JUAN ROAD
TELEPHONE:
(916) 922-0724
CITY:
SACRAMENTO
STATE:
CA
ZIP CODE:
95834
CAPACITY:
56
TOTAL ENROLLED CHILDREN:
56
CENSUS:
DATE:
09/14/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
01:10 PM
MET WITH:
Lin Boyd
TIME COMPLETED:
02:10 PM
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***THIS IS AN AMENDED REPORT***
LPA L. Habtom arrived at the facility to interview a child for a complaint filed against another licensed facility.
SUPERVISORS NAME
:
Keven Peters
LICENSING EVALUATOR NAME
:
Lea Habtom
LICENSING EVALUATOR SIGNATURE
:
DATE:
09/19/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/19/2022
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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