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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500495
Report Date: 10/17/2024
Date Signed: 10/17/2024 01:20:32 PM

Document Has Been Signed on 10/17/2024 01:20 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, 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: 14CENSUS: DATE:
10/17/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Kimberly LindseyTIME VISIT/
INSPECTION COMPLETED:
10:43 AM
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On October 17, 2024, Licensing Program Analyst (LPA) Stacey Williams met with Licensee, Kimberly Lindsey. There were eleven children present. Licensee's Assistant was also present in the home. LPA met with Licensee's Assistant to discuss the incident report submitted to Community Care Licensing on 9/30/24.


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: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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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