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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013421573
Report Date: 12/13/2023
Date Signed: 12/13/2023 11:49:58 AM

Document Has Been Signed on 12/13/2023 11:49 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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:ELLINGBERG, KATRINAFACILITY NUMBER:
013421573
ADMINISTRATOR:ELLINGBERG, KATRINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 567-3337
CITY:OAKLANDSTATE: CAZIP CODE:
94605
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
12/13/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Katrina EllingbergTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Cherie Acosta and Brindha Govindasamy conducted an unannounced Case Management inspection. LPAs met with licensee Katrina Ellingberg. Also present was licensee's two adult children/assistants, 2 infants and 10 preschool aged children in care.

An annual inspection was conducted on 11/15/23. During the visit on 11/15/23, LPA observed swing sets in the outdoor play area that were not anchored. During today's inspection swing sets were anchored to the ground for children's safety. The backyard and swing sets are observed to be safe for children in care and are approved to be used for children.

Notice of Site Visit was provided and must be posted for 30 days.
Exit interview and report reviewed with Katrina Ellingberg.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Cherie Acosta
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2023
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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