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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 574500035
Report Date: 02/22/2024
Date Signed: 02/22/2024 01:52:39 PM

Document Has Been Signed on 02/22/2024 01:52 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 SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GIBSON STATE PRESCHOOLFACILITY NUMBER:
574500035
ADMINISTRATOR:GABRIELA GARCIAFACILITY TYPE:
850
ADDRESS:312 GIBSON RDTELEPHONE:
(530) 406-5951
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 21DATE:
02/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Child Development Coordinator, Maria LewisTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Lauren Scott and Licensing Program Manager (LPM) Chayntel Hunter met with Child Development Coordinator, Maria Lewis to follow up on an Unusual Incident Report (UIR) that was reported to Community Care Licensing on 02/21/2024.

LPAs interviewed the Child Development Coordinator and teachers who were present during the incident. LPAs reviewed and discussed this report with the Child Development Coordinator.

The facility reported the UIR to Community Care Licensing within 24hrs and were reminded to submit a written UIR was submitted within 7 days.

Facility evaluation report was reviewed and discussed with Child Development Coordinator. An exit interview was conducted. A notice of site visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

In the areas that were evaluated, no deficiencies were cited during today's inspection.
SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: Lauren Scott
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2024
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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