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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 553622901
Report Date: 10/17/2024
Date Signed: 10/17/2024 02:22:48 PM

Document Has Been Signed on 10/17/2024 02:22 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:SAFARI LEARNING ACADEMY (PRESCHOOL)FACILITY NUMBER:
553622901
ADMINISTRATOR/
DIRECTOR:		KATIE PACKFACILITY TYPE:
850
ADDRESS:18470 STRIKER COURTTELEPHONE:
(209) 588-0920
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY: 112TOTAL ENROLLED CHILDREN: 112CENSUS: 51DATE:
10/17/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Ali CordovaTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tobias Lake and Licensing Program Manager (LPM) Bettina Engleman met with the facility representative for the purpose of a case management visit. During this visit, it was determined that there was an incident that occurred at the facility on 09/24/2024 that was required to be reported but was not, therefore a Type B citation will be issued, see LIC809D.

An exit interview was conducted in which the report was reviewed and discussed with Facility Representative. A Notice of Site Visit was posted by LPA and must remain posted for 30 days. Appeal rights were provided. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Tobias Lake
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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Document Has Been Signed on 10/17/2024 02:22 PM - It Cannot Be Edited


Created By: Tobias Lake On 10/17/2024 at 01:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SAFARI LEARNING ACADEMY (PRESCHOOL)
FACILITY NUMBER: 553622901

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/18/2024
Section Cited
CCR
101212(d)

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Upon the occurrence... a report shall be made to the Department... within the Department's next working day and during its normal business hours. In addition, a written report... shall be submitted to the Department within seven days... This requirement was not met as evidenced by:
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Facility Representative will submit an Unsual Incident Report related to the incident that occured on 9/24/24 to the Department by 10/18/24.
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Upon interview with staff, it was discovered that an incedent occuring on 9/24/24 was not reported to the Department which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bettina Engelman
LICENSING EVALUATOR NAME:Tobias Lake
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


LIC809 (FAS) - (06/04)
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