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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393607795
Report Date: 03/08/2023
Date Signed: 03/22/2023 01:25:53 PM

Document Has Been Signed on 03/22/2023 01:25 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:MERLO PRESCHOOLFACILITY NUMBER:
393607795
ADMINISTRATOR:SOUPHONE LAEMFACILITY TYPE:
850
ADDRESS:1670 EAST SIXTH STREETTELEPHONE:
(209) 933-7190
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 10DATE:
03/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Lead PM Teacher Souphone LaemTIME COMPLETED:
03:00 PM
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This is an amended version of a report, originally created on 3/8/23.

Licensing Program Analyst (LPA) Carla Polanco met with Lead PM teacher Souphone Laem to follow up on a Unusual Incident Report (UIR) called into Community Care Licensing on 3/1/23. During today's inspection LPA conducted a tour of the facility.

LPA conducted interviews and obtained information pertinent to the incident.

Facility evaluation report was reviewed and discussed with Lead PM Teacher Souphone Laem. Exit interview was conducted. A Notice of Site Visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.



In the areas that were evaluated, no deficiencies were cited during today's inspection.
SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Carla Polanco Rivera
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2023
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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