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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
343624916
Report Date:
08/15/2024
Date Signed:
08/19/2024 02:52:36 PM
Document Has Been Signed on
08/19/2024 02:52 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:
MISSION AVENUE PRESCHOOL
FACILITY NUMBER:
343624916
ADMINISTRATOR/
DIRECTOR:
CHRISTINA DIAZ BUSHMAN
FACILITY TYPE:
830
ADDRESS:
2433 MISSION AVENUE
TELEPHONE:
(916) 487-4647
CITY:
CARMICHAEL
STATE:
CA
ZIP CODE:
95608
CAPACITY:
19
TOTAL ENROLLED CHILDREN:
19
CENSUS:
6
DATE:
08/15/2024
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:
Nicole Moran-Estrada
TIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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This is an amended version of the original report created on 8/15/2024.
SUPERVISORS NAME
:
Seychelle De Luca
LICENSING EVALUATOR NAME
:
Josiah Gathing
LICENSING EVALUATOR SIGNATURE
:
DATE:
08/15/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/15/2024
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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