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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623185
Report Date: 11/28/2023
Date Signed: 11/28/2023 10:38:35 AM

Document Has Been Signed on 11/28/2023 10:38 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:SETA - CP HUNTINGTON HEAD STARTFACILITY NUMBER:
343623185
ADMINISTRATOR:SHANNON MATLOCKFACILITY TYPE:
850
ADDRESS:5917 26TH STREETTELEPHONE:
(916) 263-3800
CITY:SACRAMENTOSTATE: CAZIP CODE:
95822
CAPACITY: 36TOTAL ENROLLED CHILDREN: 36CENSUS: 26DATE:
11/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Shannon MatlockTIME COMPLETED:
10:50 AM
NARRATIVE
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Licensing Program Analyst (LPA) Christopher Bello arrived at the facility at approximately 10:10am and met with Director, Shannon Matlock regarding an Unusual Incident that took place November 27th, 2023. LPA made observations and interviewed the director.

Director stated that they have spoken to staff regarding the incident and have a training that they scheduled a training on December 1, 2023 to prevent further incidents from occurring in the future.

Title 22 Deficiencies have been cited on the attached LIC 809D. Upon receipt of Type A citations, facility shall post and provide copies of the LIC 809D for parents/guardians of children currently in care and for parents/guardians of newly enrolled children for the next 12 months. Facility must also keep the signed LIC 9224, Acknowledging Receipt of Licensing Reports LIC 809D in each child's files.

This report was reviewed and discussed with licensee. A notice of site visit and appeal rights were provided.

SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Christopher Bello
LICENSING EVALUATOR SIGNATURE: DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/28/2023
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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Document Has Been Signed on 11/28/2023 10:38 AM - It Cannot Be Edited


Created By: Christopher Bello On 11/28/2023 at 10:25 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SETA - CP HUNTINGTON HEAD START
FACILITY NUMBER: 343623185

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/29/2023
Section Cited
CCR
101229(a)(1)

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No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation. This requirement has not been met by evidence: Facility self-reported an incident. This is considered as an
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Facility self-reported the incident. Director spoke to staff and has scheduled a training regarding the incident. LPA will return to facility to clear deficiency.
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immediate risk to the children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Amanda Blesi
LICENSING EVALUATOR NAME:Christopher Bello
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023


LIC809 (FAS) - (06/04)
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