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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500515
Report Date: 10/27/2023
Date Signed: 10/29/2023 09:52:09 PM

Document Has Been Signed on 10/29/2023 09:52 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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GILLUM, DENISHAFACILITY NUMBER:
394500515
ADMINISTRATOR:GILLUM, DENISHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 955-9942
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 8DATE:
10/27/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:12 PM
MET WITH:Denisha GillumTIME COMPLETED:
02:00 PM
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On 10/27/23, Licensing Program Analyst (LPA) Elvira Sierra met with licensee, Denisha Gillum for a Case Management inspection.

Licensee had requested to make the formerly off-limits Bedroom #1 to be made on-limits. LPA toured the facility, focusing on bedroom #1. LPA did not observe any hazards, and approves the use of Bedroom #1 for child care. The new off-limit areas are: Bedroom # 2 or master bedroom bathroom # 2 (inside master bedroom), and garage.

No deficiencies were observed at today's inspection.

Due to printer issues A Notice of Site Visit will be sent to provider an exit interview was conducted.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Elvira Sierra
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2023
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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