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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313620931
Report Date: 10/24/2023
Date Signed: 10/24/2023 12:43:38 PM

Document Has Been Signed on 10/24/2023 12:43 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:JOHNSON, SHANNONFACILITY NUMBER:
313620931
ADMINISTRATOR:JOHNSON, SHANNONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 440-6620
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 10DATE:
10/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Shannon JohnstonTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Michelle Perez, met with licensee, Shannon Johnson for an unannounced random inspection. All individuals subject to criminal background review have obtained a criminal record clearance. Today’s census was 10 children present with two assistants. Operating hours are 7:30am to 4:30pm.

A health and safety inspection was conducted in all areas accessible to children. Off-limits areas include 2 bathrooms upstairs, kitchen and garage.

LPA observed a working phone, fire extinguisher, and functioning smoke and carbon monoxide detectors. Assistant stated there are no weapons in the home. Toxic and hazardous items (detergents, cleaning compounds, medications, sharp utensils, items that could pose a danger to children in care) are properly stored and inaccessible to children. The fireplace in the home is appropriately barricaded to prevent access by children. Stairs were barricaded. Safe toys and play equipment are observed. The outdoor play space is fenced. The backyard is fenced and gated. There are no bodies of water observed.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Michelle Perez
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: JOHNSON, SHANNON
FACILITY NUMBER: 313620931
VISIT DATE: 10/24/2023
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Some children’s files were reviewed. A current roster is being maintained. Licensee fire and disaster drills are conducted and documented. Last fire drill completed October 2024. CPR and first aid training were verified to be current for licensee. CPR expires October 2024 and Mandated Reporter Training (AB 1207) expires (for all) June 2025.

This provider is currently not providing IMS services to children in care. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department.

The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/(800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

LPA verified the annual fees are current. LPA provided the Child Care Advocates Program email address: childcareadvocatesprogram@dss.ca.gov, so the Licensee can request to be added to the distribution list to receive Quarterly Updates.

LPA reviewed and discussed this facility evaluation report with the licensee, Shannon Johnson. LPA provided a Notice of Site Visit and Destiny acknowledges that this notice should remain posted for 30 days for parental review.



Per California Code of Regulations, Title 22, Division 12, Chapter 1, no deficiencies are cited during today's inspection.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Michelle Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023
LIC809 (FAS) - (06/04)
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