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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393602276
Report Date: 05/23/2024
Date Signed: 05/23/2024 10:58:03 AM

Document Has Been Signed on 05/23/2024 10:58 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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CARLSON, SARAHFACILITY NUMBER:
393602276
ADMINISTRATOR/
DIRECTOR:		CARLSON, SARAHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 298-9554
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
05/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Nevin MckissickTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
NARRATIVE
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On 05/23/24, Licensing Program Analysts (LPA),Elvira Sierra, conducted a case management inspection to verified correction on deficiency cited on 04/04/24 and met with Licensee's Assistant, Nevin Mckissick. No children were present. Licensee was not at the facility, and assistant stated she was on vacation. LPA spoke to Licensee over the phone and explained that absences shall not exceed 20 percent of the hours that the facility is providing care per day. Licensee must notify the department anytime facility is closing for vacation or any other leave that requires to be absence more than 20 percent per day.

LPA observed proof of CPR certification for Licensee's assistant on today's visit. Deficiency cited on 04/04/24 have been cleared on today's inspection.

Deficiency is cited on subsequent page of this report. Exit interview conducted. The report and Appeal of Rights were reviewed and provided to Licensee's Assistant, Nevin Mckissick. .


SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Elvira Sierra
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2024
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 05/23/2024 10:58 AM - It Cannot Be Edited


Created By: Elvira Sierra On 05/23/2024 at 10:43 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: CARLSON, SARAH
FACILITY NUMBER: 393602276

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2024
Section Cited
CCR
102417(a)

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102417 Operation of a Family Child Care Home.a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times. When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a
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POC: LPA spoke to Licensee over the phone and she stated facility will be closed until she come back from vacation on Monday 27,2024. LPA will received a statement from Licensee to clear citation upon her return.
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substitute adult to care for and supervise the children during his/her absence. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day.This requirement was not met as evidence by: Licensee's assitant informed LPA that Licensee was on vacation. This is a requirement that if not corrected can pose a risk to the health and safety of 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:Bettina Engelman
LICENSING EVALUATOR NAME:Elvira Sierra
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024


LIC809 (FAS) - (06/04)
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