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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313619587
Report Date: 05/08/2024
Date Signed: 05/08/2024 12:16:40 PM

Document Has Been Signed on 05/08/2024 12:16 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:MERRYHILL SCHOOL - FOOTHILLSFACILITY NUMBER:
313619587
ADMINISTRATOR/
DIRECTOR:		NATASA ZIVKOVICFACILITY TYPE:
830
ADDRESS:3989 FOOTHILLS BOULEVARDTELEPHONE:
(916) 782-2500
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 99DATE:
05/08/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Natasa Zivkovic - DirectorTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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An unannounced case management inspection was conducted today by Licensing Program Analyst Owens. LPA Owens met with Director, Natasa Zivkovic. The purpose of the inspection is to confirm removal of employee, Jacy Ned.

Natasa Zivkovic confirmed Jacy Ned has not been employed at the facility for about a year. Community Care Licensing did receive the signed Confirmation of removal form LIC 300 A, date stamped April 15, 2024 from Natasa Zivkovic. The LIC 300 form indicated on 11/13/ 2023 Jacy Ned was removed and was no longer employed at the facility.

No citation issued.

Notice of Site visit given at time of inspection.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Katrina Owens
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2024
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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