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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313622153
Report Date: 01/29/2024
Date Signed: 01/29/2024 11:43:59 AM

Document Has Been Signed on 01/29/2024 11:43 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:LITTLE SUNSHINE'S PLAYHOUSE & PS - GRANITE BAYFACILITY NUMBER:
313622153
ADMINISTRATOR:MARCI PILGRIMFACILITY TYPE:
850
ADDRESS:5370 DOUGLAS BLVDTELEPHONE:
(916) 605-0217
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY: 96TOTAL ENROLLED CHILDREN: 96CENSUS: 76DATE:
01/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Marci PilgrimTIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Jeremey McClain met with facility representative Marci Pilgrim for an unannounced Case Management Inspection regarding an Unusual Incident Report.

Upon arrival, LPA observed 76 children supervised by 10 staff members.

On 01/15/2024 it was reported that on 01/12/2024, Child 1 received a head injury after they were ran into by another child on the playground, causing them to hit the front of their head on brick padding outside. Child 1 was attended to immediately and their parents were notified. The child received a stitch to the wound over the weekend and returned to care the following week.

During today’s inspection LPA spoke with Staff 1 who observed the incident. LPA also observed the area where the accident occurred. LPA reviewed the facility report that was reviewed and signed by Child #1’s parents.

LPA determined that the incident was not due to a lack of supervision, nor were there any Title 22 deficiencies related to the incident. LPA did not observe any hazards on the playground where the injury occurred. Exit interview conducted and report was reviewed by facility representative Marci Pilgrim. LPA provided a Notice of Site Visit that shall remain posted for 30 days.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Jeremey McClain
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2024
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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