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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393607283
Report Date: 08/22/2024
Date Signed: 08/22/2024 01:06:22 PM


Document Has Been Signed on 08/22/2024 01:06 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:ADAMS ELEMENTARY SCHOOLFACILITY NUMBER:
393607283
ADMINISTRATOR:TIM SWARTZFACILITY TYPE:
850
ADDRESS:6402 INGLEWOOD AVE.TELEPHONE:
(209) 953-3000
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:48CENSUS: 21DATE:
08/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Kellany MendozaTIME COMPLETED:
11:30 AM
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On 08/22/24, Licensing Program Analyst (LPA)Elvira Sierra met with Head Start Lead Teacher, Kellany Mendoza for the purpose of conducting an unannounced case management visit to follow up on an Unusual Incident Report that occurred on 08/16/24. Upon arrival LPA observed 12 children in the Head Start Classroom (Portable classroom #41) supervised by three staff members and 9 children in the State Classroom (classroom #1)supervised by six staff members.

LPA conducted interviews, inspected play ground/equipment and observed the care and supervision of the children during today's visit.

No Title 22 deficiencies were observed or were cited on today’s date. Exit interview was conducted, and report was reviewed with Facility Representative, Kellany Mendoza. A Notice of Site Visit was posted and should remain posted for a period of 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Elvira SierraTELEPHONE: (916) 216-8826
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024
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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