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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 573614564
Report Date: 03/28/2024
Date Signed: 04/03/2024 10:45:45 AM

Document Has Been Signed on 04/03/2024 10:45 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:PEREGRINE SCHOOLFACILITY NUMBER:
573614564
ADMINISTRATOR:VIDRIO, FABIOLAFACILITY TYPE:
850
ADDRESS:2907 PORTAGE BAY WESTTELEPHONE:
(530) 758-8845
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 34DATE:
03/28/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Heidi AmadorTIME COMPLETED:
10:55 AM
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Licensing Program Analyst (LPA) Jennie conducted a case management inspection to verify the removal of an excluded individual, Shah Naveed. LPA met with Assistant Director, Heidi Amador and confirmed Shah Naveed has been removed and is not working at the facility. LPA observed 34 children supervised by 11 staff. Criminal record clearances have been verified.

LPA did not observe Shah Naveed to be present at the facility today. Assistant Director, Heidi Amador, stated that there is no recollection of an employee or volunteer by the name of Shah Naveed having worked at the facility in the last 4 years. LPA did not observe the employee's records during personnel record review.

Today, the Assistant Director, Heidi Amador, was advised and understands that the individual listed above cannot be present at this facility or any other Peregrine Facility.

An exit interview was conducted with today Assistant Director.

LPA reviewed report with the Assistant Director, and provided copies of the report along with Appeal Rights. A notice of site visit was provided and posted by LPA and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.


No Title 22 Deficiencies were cited during the visit.

Verification of removal is complete.
SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Jennie Tedlos
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2024
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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