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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500179
Report Date: 05/04/2022
Date Signed: 05/04/2022 12:09:21 PM

Document Has Been Signed on 05/04/2022 12:09 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:SHRECKENGOST, AMANDAFACILITY NUMBER:
394500179
ADMINISTRATOR:SHRECKENGOST, AMANDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 740-0743
CITY:STOCKTONSTATE: CAZIP CODE:
95219
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
05/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:licensee, Amanda ShreckengostTIME COMPLETED:
12:20 PM
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Licensing Program Analysts (LPAs) Lauren Scott and Chayntel Hunter met with licensee, Amanda Shreckengost to follow up on an Unusual Incident Report (UIR) submitted to Community Care Licensing on 05/02/2022. During today's visit the facility was toured. Present were 12 children present as well as licensee's assistant/ husband.

LPAs interviewed the licensee who was present during the incident. LPAs reviewed and discussed this report with the licensee.

The facility reported the UIR to Community Care Licensing within 24hrs, on Thursday April 27, 2022. A written UIR was submitted within 7 days, describing the specifics of the incident.

Facility evaluation report was reviewed and discussed with licensee. 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: Justin L Denton
LICENSING EVALUATOR NAME: Lauren Scott
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2022
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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