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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393604765
Report Date: 09/24/2025
Date Signed: 09/24/2025 03:15:01 PM

Document Has Been Signed on 09/24/2025 03:15 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 SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CATALYST KIDS - JACOBSONFACILITY NUMBER:
393604765
ADMINISTRATOR/
DIRECTOR:		ELIZABETH GOODWINFACILITY TYPE:
840
ADDRESS:1750 KAVANAGH STREETTELEPHONE:
(209) 832-8799
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY: 70TOTAL ENROLLED CHILDREN: 70CENSUS: 24DATE:
09/24/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Friba LutfiTIME VISIT/
INSPECTION COMPLETED:
03:34 PM
NARRATIVE
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On September 24, 2025, Licensing Program Analyst (LPA) Stacey Williams met with Facility Representative,Friba Lutfi for the purpose of a case management inspection. LPA observed twenty four children supervised by 5 staff.

On September 17, 2025, Community Care Licensing (CCL) received notification of an incident involving four school-age children that were left outside alone for approximately two minutes. Per reporting party and written incident report submitted, the incident occurred on September 15, 2025. CCL was notified two days after the incident occurred. Per incident report, name to face headcounts are required at each transition and the meeting spot outside to transition inside has been changed to make it easier to supervise as a result of the incident.

Title 22 Deficiencies have been cited on the attached LIC 8099D. 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 Report LIC 809D in each child's files.

Exit interview conducted at which time the report was reviewed with Facility Representative, Friba Lutfi. A Notice of Site Visit was posted by LPA Williams and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.00.
NAME OF LICENSING PROGRAM MANAGER: Bettina Engelman
NAME OF LICENSING PROGRAM ANALYST: Stacey Williams
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 09/24/2025 03:15 PM - It Cannot Be Edited


Created By: Stacey Williams On 09/24/2025 at 02:01 PM
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: CATALYST KIDS - JACOBSON
FACILITY NUMBER: 393604765

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/25/2025
Section Cited
HSC
1596.99(c)(3)(c)

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The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation and one hundred dollars ($100) for each day the violation continues .... :(3) Absence of supervision, including, but not limited to, a child left unattended, and supervision of a child by a person under 18 years of age.
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Facility Representative stated that all employees will be trained on how to do roll call and each transition going outside and inside classrooms. Name to face headcounts will be done immediately. Facility Representative will provide a written statement outlining new procedures for transitioning.
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This requirement was not met as evidence by: Community Care Licensing was notified of an incident where four children were left outside of the classroom unsupervised without staff's knowledge and brought back to the classroom by a family member. This poses an immediate risk to the health and safety of children in care.
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Civil Penalty of five hundred dollars($500.00) will be assess on the next page (LIC 421M)

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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.
Bettina Engelman
NAME OF LICENSING PROGRAM MANAGER:
Stacey Williams
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/24/2025 03:15 PM - It Cannot Be Edited


Created By: Stacey Williams On 09/24/2025 at 02:08 PM
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: CATALYST KIDS - JACOBSON
FACILITY NUMBER: 393604765

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/15/2025
Section Cited
CCR
101212(d)(1)(C)

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Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours.(C) Any unusual incident or child absence that threatens the physical or emotional health or safety of any child.
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Facility Representative stated that all staff will be retrained on unusual incident report requirements. Training roster and material will be submitted to CCL by POC date.
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This requirement was not met as evidenced by: Community Care Licensing was notified of an unusual incident involving four children left outside unsupervised. The incident was reported to CCL two days after the incident occurred. This is a potential risk to the health and safety of 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.
Bettina Engelman
NAME OF LICENSING PROGRAM MANAGER:
Stacey Williams
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2025


LIC809 (FAS) - (06/04)
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