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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 293614615
Report Date: 07/18/2024
Date Signed: 07/18/2024 12:35:49 PM

Document Has Been Signed on 07/18/2024 12:35 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 CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CARE CAMPUS CHILDREN'S CENTERFACILITY NUMBER:
293614615
ADMINISTRATOR/
DIRECTOR:
GUSTAVSON, SANDEEFACILITY TYPE:
850
ADDRESS:10746 SIERRA ROSE CT.TELEPHONE:
(530) 268-8252
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95949
CAPACITY: 45TOTAL ENROLLED CHILDREN: 45CENSUS: 38DATE:
07/18/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Sandee GustavsonTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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At 9:30am on 7/18/2024, Licensing Program Analyst (LPA) Matthew Gallo met with facility representative Sandee Gustavson for the purpose of an unnanounced case management visit regarding a self-reported unusual incident. Today's census included 38 preschool children supervised by 6 staff.

On 6/26/2024, licensing received a report from the facility detailing an incident of inappropriate touching between two children that had occurred on the outdoor play yard the previous day, 6/25/2024. According to the report, the two children were on the play structure when one child pulled down another child's pants and touched their privates. During today's visit, LPA conducted interviews with staff and observed the play yard. According to interviews, at least 5 staff were present and providing supervision at the time of the incident, and a teacher stopped the behavior moments after it started. The available information does not indicate that the incident was due to a lack of supervision.

No Title 22 deficiences are cited as a result of the incident.

Exit interview conducted and report was reviewed with the facility representative, Sandee Gustavson. A notice of site visit was given and must remain posted for 30 days. Appeal rights provided.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Matthew Gallo
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2024
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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