Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393607283
Report Date: 05/09/2019
Date Signed: 05/09/2019 03:43:08 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:ADAMS ELEMENTARY SCHOOLFACILITY NUMBER:
393607283
ADMINISTRATOR:WOMBLE, SHARONFACILITY TYPE:
850
ADDRESS:6402 INGLEWOOD AVE.TELEPHONE:
(209) 953-3000
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:48CENSUS: 14DATE:
05/09/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Brenda DeAlbaTIME COMPLETED:
03:44 PM
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Licensing Program Analyst (LPA) Stacey Williams met with Lead Teacher Brenda DeAlba for a case management inspection regarding an unusual incident report submitted to Community Care Licensing. LPA observed 14 children supervised by two staff.

LPA conducted interviews with staff during today's inspection.

Further investigation is needed. No title 22 deficiencies were cited. Notice of site visit was provided and posted.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Stacey WilliamsTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2019
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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