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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343618736
Report Date: 11/07/2023
Date Signed: 11/07/2023 10:12:09 AM

Document Has Been Signed on 11/07/2023 10:12 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:MILHOLM, JILL MARIEFACILITY NUMBER:
343618736
ADMINISTRATOR:MILHOLM, JILL MARIEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 698-7460
CITY:SACRAMENTOSTATE: CAZIP CODE:
95822
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
11/07/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Jill Marie MilholmTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Christopher Bello arrived at the facility at approximately 9:40am for a Plan of Correction inspection regarding the deficiencies cited on LIC809D dated 10/17/2023. LPA met with Jill Marie Milholm. No other adults present at time of inspection. Today’s census was five 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 licensee [or facility representative] Jill Marie Milholm.
SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Christopher Bello
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2023
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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