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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393605862
Report Date: 10/22/2024
Date Signed: 10/22/2024 11:48:10 AM

Document Has Been Signed on 10/22/2024 11:48 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 SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CATALYST KIDS - JACOBSONFACILITY NUMBER:
393605862
ADMINISTRATOR/
DIRECTOR:		ANDIANA SERRANOFACILITY TYPE:
850
ADDRESS:1750 KAVANAGH STREETTELEPHONE:
(209) 832-8799
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY: 48TOTAL ENROLLED CHILDREN: 20CENSUS: 10DATE:
10/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:38 AM
MET WITH:Andiana SerranoTIME VISIT/
INSPECTION COMPLETED:
11:33 AM
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On October 22, 2024, Licensing Program Analyst (LPA) Stacey Williams met with Program Lead, Andiana Serrano. LPA observed (10) ten children supervised by 3 staff.

LPA conducted interviews with children pertaining to the incident reported to Community Care Licensing on September 23, 2024.

Exit interview conducted and report was reviewed with Program Lead, Andiana Serrano . A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2024
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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