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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500459
Report Date: 09/15/2022
Date Signed: 09/15/2022 10:44:26 AM

Document Has Been Signed on 09/15/2022 10:44 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:WILLIAMS, JER'NEEFACILITY NUMBER:
394500459
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
09/15/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Licensee, Jernee WilliamsTIME COMPLETED:
11:00 AM
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Licensing Program Analysts (LPA) Lauren Scott met with Licensee, Jernee Williams on September 15, 2022 for the purpose of an unannounced plan of correction inspection to clear a Type B deficiency, which was issued on 8/18/22 for not having proper documentation in children's files, specifically LIC700.

During today's inspection LPAs toured all areas accessible to children in care and reviewed all files for enrolled children. Upon review, LPA found all appropriate documents were available.

Deficiency cited on 8/18/22 is cleared effective today. Proof of correction letter was provided. 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.

SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: Lauren Scott
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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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