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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340311928
Report Date: 07/07/2023
Date Signed: 07/07/2023 01:12:32 PM

Document Has Been Signed on 07/07/2023 01:12 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 - GENEVIEVE DIDIONFACILITY NUMBER:
340311928
ADMINISTRATOR:FERNANDEZ, JACOBFACILITY TYPE:
840
ADDRESS:6490 HARMON DR.TELEPHONE:
(916) 433-6675
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY: 150TOTAL ENROLLED CHILDREN: 150CENSUS: 52DATE:
07/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Jake FernandezTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christopher Bello arrived at approximately 11:45am met with Director, Jake Fernandez, regarding an Unusual Incident that took place June 28th, 2023. LPA made observations and interviewed staff regarding the incident. Staff self-reported the incident to the Sacramento Regional Office.

Director stated that they have done training in the past and will conduct another in the near future to prevent incidents like these from happening in the future.

Title 22 Deficiencies have been cited on the attached LIC 809D. Upon receipt of Type A citations, facility shall post and provide copies of the LIC 809D for parents/guardians of children currently in care and for parents/guardians of newly enrolled children for the next 12 months. Facility must also keep the signed LIC 9224, Acknowledging Receipt of Licensing Reports LIC 809D in each child's files

This report was reviewed and discussed with licensee. A notice of site visit and appeal rights were provided.

SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Christopher Bello
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2023
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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Document Has Been Signed on 07/07/2023 01:12 PM - It Cannot Be Edited


Created By: Christopher Bello On 07/07/2023 at 12:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: 4TH R - GENEVIEVE DIDION
FACILITY NUMBER: 340311928

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2023
Section Cited
CCR
101229(a)(1)

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No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation. This requirement has not been met by evidence: Facility self-reported the incident. This is considered as an
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Director stated that they have performed training in the past and will conduct another regarding this incident. LPA will return to clear the deficiency and to review LIC9224.
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immediate risk to the children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Amanda Blesi
LICENSING EVALUATOR NAME:Christopher Bello
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023


LIC809 (FAS) - (06/04)
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