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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500581
Report Date: 09/20/2023
Date Signed: 09/20/2023 11:49:07 AM

Document Has Been Signed on 09/20/2023 11:49 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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:LIBERTY SQUARE CHILD DEVELOPMENT CENTERFACILITY NUMBER:
394500581
ADMINISTRATOR:HER, JENNIFERFACILITY TYPE:
850
ADDRESS:807 N. SAN JOAQUIN ST. SUITE BTELEPHONE:
(209) 623-7962
CITY:STOCKTONSTATE: CAZIP CODE:
95202
CAPACITY: 20TOTAL ENROLLED CHILDREN: 13CENSUS: 10DATE:
09/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Maham KamranTIME COMPLETED:
12:00 PM
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On 09/20/23, Licensing Program Analyst (LPA) Elvira Sierra conducted an unannounced case management inspection and met with Site Supervisor, Maham Kamran. Purpose of the inspection was to follow up on an incident that occurred on 09/13/23. Facility is in compliance with Staff/Child ratios on today's inspection.

During today's inspection LPA inspected the facility, interviewed staff and obtained documents pertaining to the incident. The facility reported the Unusual Incident to Community Care Licensing and a written UIR was submitted within 7 days, describing the specifics of the incident.

Notice of Site Visit was posted. The Notice of Site Visit must remain posted for 30 days. Failure to maintain posting as required will result in a civil penalty of $100.00.



The report was discussed with Site Supervisor, Mahan Kamran and an exit interview was conducted.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Elvira Sierra
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2023
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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