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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343619193
Report Date: 09/27/2023
Date Signed: 09/27/2023 02:03:08 PM

Document Has Been Signed on 09/27/2023 02:03 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MARTIN, JILLIANFACILITY NUMBER:
343619193
ADMINISTRATOR:MARTIN, JILLIANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 670-1136
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
09/27/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Jillian MartinTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Christopher Bello arrived at the facility at approximately 1:40pm for a Plan of Correction inspection regarding the deficiencies cited on LIC809D dated 8/22/23. LPA met with Jillian Martin. Also present was licensee’s husband. Present at time of inspection there were four children.

Based upon today’s inspection, LPA’s observed that all deficiencies are cleared as of today.

No Title 22 Deficiencies observed in the areas that were evaluated. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee [or facility representative] Jillian Martin.
SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Christopher Bello
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2023
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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