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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623896
Report Date: 06/22/2023
Date Signed: 08/10/2023 04:31:20 PM

Document Has Been Signed on 08/10/2023 04:31 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:DISCOVERY TREE SCHOOL - CAPITAL CITYFACILITY NUMBER:
343623896
ADMINISTRATOR:HEBERT, KAPRIAFACILITY TYPE:
850
ADDRESS:744 P STREETTELEPHONE:
(916) 965-3661
CITY:SACRAMENTOSTATE: CAZIP CODE:
95814
CAPACITY: 58TOTAL ENROLLED CHILDREN: 58CENSUS: 14DATE:
06/22/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Kapria HebertTIME COMPLETED:
10:50 AM
NARRATIVE
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This is amended version of the original report created on 6/22/2023. Facility was incorrectly cited and upon review by Licensing Program Manager (LPM) Seychelle De Luca, the deficiency has been dismissed.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Matthew Gallo
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2023
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 06/22/2023 10:42 AM - It Cannot Be Edited


Created By: Matthew Gallo On 06/22/2023 at 10:13 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: DISCOVERY TREE SCHOOL - CAPITAL CITY
FACILITY NUMBER: 343623896

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
06/23/2023
Section Cited
CCR
101216.3

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(a) There shall be a ratio of one teacher visually observing and supervising no more than 12 children in attendance, except as specified in (b) and (c) below.

This requirement was not met as evidenced by:
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Director will provide LPA with a signed statement from the executive team stating that they are in the process of hiring additional teachers.
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LPA determined through observation, interview, and record review that a group of 6 children were left alone with an aide and no qualified teachers while Director greeted LPA and guided him through a tour of the facility.
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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:Keven Peters
LICENSING EVALUATOR NAME:Matthew Gallo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023


LIC809 (FAS) - (06/04)
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