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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500495
Report Date: 09/30/2024
Date Signed: 09/30/2024 10:46:38 AM

Document Has Been Signed on 09/30/2024 10:46 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:LINDSEY, KIMBERLYFACILITY NUMBER:
394500495
ADMINISTRATOR/
DIRECTOR:		KIMBERLY LINDSEYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 603-9832
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 0DATE:
09/30/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Kimberly LindseyTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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On September 30, 2024, Licensing Program Analyst (LPA) Stacey Williams met with Licensee, Kimberly Lindsey. Licensee informed LPA that she is closed for day to disinfect the facility. There were no children present. Licensee spoke to LPA about an incident that occurred on September 27, 2024 pertaining to C1. Licensee stated that she reported the incident to Community Care Licensing on 9/30/24. Licensee provided a copy of the written incident report to LPA during today's visit. Licensee discussed the incident with LPA and will provide additional information related to the incident via email.


Exit interview conducted. 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: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
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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