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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313602542
Report Date: 03/11/2024
Date Signed: 03/11/2024 02:14:34 PM

Document Has Been Signed on 03/11/2024 02:14 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:STAR MAIDUFACILITY NUMBER:
313602542
ADMINISTRATOR:JENNIFER WALKERFACILITY TYPE:
840
ADDRESS:1950 JOHNSON RANCH ROADTELEPHONE:
(916) 782-8454
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY: 300TOTAL ENROLLED CHILDREN: 300CENSUS: 0DATE:
03/11/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Jennifer WalkerTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Jeremey McClain met with facility representative Jennifer Walker for an unannounced Case Management Inspection regarding an Unusual Incident Report.

No children were in care during the inspection.

It was reported that on 02/23/2024 a child suffered a fractured elbow after falling from a play structure and landing on their elbow. The student that was injured and the staff that observed it were from another STAR program that was combining with the Maidu program during a camp. LPA observed the play structure where the incident occurred for potential hazards.

LPA will follow up with the director and child at their respective facility in order to get more information regarding the incident.

An exit interview was conducted, and this report was reviewed with facility representative Jennifer Walker. A Notice of Site Visit was provided and shall remain posted for 30 days.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Jeremey McClain
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2024
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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