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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340310500
Report Date: 06/19/2024
Date Signed: 06/19/2024 03:49:19 PM

Document Has Been Signed on 06/19/2024 03:49 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:4TH R - CROCKER RIVERSIDEFACILITY NUMBER:
340310500
ADMINISTRATOR/
DIRECTOR:		AMY BROWNFACILITY TYPE:
840
ADDRESS:2970 RIVERSIDE BLVDTELEPHONE:
(916) 264-8385
CITY:SACRAMENTOSTATE: CAZIP CODE:
95818
CAPACITY: 150TOTAL ENROLLED CHILDREN: 150CENSUS: 33DATE:
06/19/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Amy BrownTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On June 19, 2024 at 1:30p.m. Licensing Program Analysts (LPA) Pa Dao Vang met with facility representative Amy Brown, for a case-management inspection for an unusual incident that occurred on 6/7/2024. Upon arrival 33 preschool children were present supervised by 6 staff members. LPA made observations, conducted interviews, and reviewed staff files.

The facility self-reported an Unusual Incident Report LIC624 to the regional office on 6/11/2024. Throughout the course of the investigation, there are no Title 22 violation pertaining to the incident.

This report was reviewed with facility representative Amy Brown. A copy of this report, appeal rights, and a notice of site visit was provided to be posted for 30 consecutive days.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Dao Vang
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2024
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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