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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 574500485
Report Date: 09/10/2024
Date Signed: 09/10/2024 10:55:41 AM

Document Has Been Signed on 09/10/2024 10:55 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 SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:YCOE MARGUERITE MONTGOMERYFACILITY NUMBER:
574500485
ADMINISTRATOR/
DIRECTOR:		GENET TELAHUN/SILVIA MEZAFACILITY TYPE:
850
ADDRESS:1441 DANBURY STREETTELEPHONE:
(530) 668-3010
CITY:DAVISSTATE: CAZIP CODE:
95618
CAPACITY: 48TOTAL ENROLLED CHILDREN: 48CENSUS: 19DATE:
09/10/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Katrina HopkinsTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Lauren Scott met with facility representative, Katrina Hopkins, to follow up on an Unusual Incident Report (UIR) that was reported to Community Care Licensing on 08/30/2024.

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

LPA conducted interviews with staff that were present during the incident.

Facility evaluation report was reviewed and discussed with the facility representative. 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: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2024
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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