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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340311928
Report Date: 07/18/2023
Date Signed: 07/18/2023 09:07:13 AM

Document Has Been Signed on 07/18/2023 09:07 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: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: 31DATE:
07/18/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Jacob FernandezTIME COMPLETED:
09:20 AM
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Licensing Program Analyst (LPA) Christopher Bello arrived at the facility at approximately 8:30am for a Plan of Correction inspection regarding the deficiencies cited on LIC809D dated 7/7/2023. LPA met with Site Supervisor Jacob Fernandez. Present at time of inspection there were 33 children.

Based upon today’s inspection, LPA’s observed that all deficiencies are cleared as of today.

No Title 22 Deficiencies observed in the areas that were evaluated. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Site Supervisor Jacob Fernandez.
SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Christopher Bello
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023
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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