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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343614029
Report Date: 10/19/2021
Date Signed: 10/19/2021 04:05:24 PM

Document Has Been Signed on 10/19/2021 04:05 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:SMALLVILLE PRESCHOOLFACILITY NUMBER:
343614029
ADMINISTRATOR:NULL SHANNONFACILITY TYPE:
850
ADDRESS:4706 ARDEN WAYTELEPHONE:
(916) 480-0632
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 30TOTAL ENROLLED CHILDREN: 30CENSUS: 16DATE:
10/19/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Shannon NullTIME COMPLETED:
04:20 PM
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At 2:50 p.m. on Tuesday, October 19th, 2021, Licensing Program Analyst (LPA) Karyn Guerra met with Licensee, Shannon Null, for the purpose of a case management inspection. LPA conducted interviews and it was learned that the facility did not follow up with an unusual incident report to the department following an event that required reporting. Licensee stated that they spoke to an Analyst to inquire about follow up requirements. LPA conducted technical assistance and reviewed reporting requirements.

No title 22 deficiencies were cited during today's inspection. An exit interview was conducted and a notice of site visit provided. Notice of site visit shall remain posted for a period of 30 days for parental review.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Karyn Guerra
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2021
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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