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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624917
Report Date: 08/15/2024
Date Signed: 08/19/2024 02:42:27 PM

Document Has Been Signed on 08/19/2024 02:42 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 PRESCHOOLFACILITY NUMBER:
343624917
ADMINISTRATOR/
DIRECTOR:		CHRISTINA DIAZ BUSHMANFACILITY TYPE:
850
ADDRESS:2433 MISSION AVENUETELEPHONE:
(916) 487-4647
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 44TOTAL ENROLLED CHILDREN: 44CENSUS: DATE:
08/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Nicole Moran-EstradaTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On Thursday, August 15, 2023 at approximately 9:30 AM Licensing Program Analyst Josiah Gathing met with Director Nicole Moran-Estrada for the purpose of an unannounced Case Management investigation. The purpose of this inspection was to follow up on a self-reported incident submitted to the Licensing Program office on July 16, 2024. During the investigation LPA conducted interviews and reviewed records.

A notice of site visit was given and must remain posted for 30 days. Exit interview was conducted and report was reviewed with the Director. This report and appeal rights were printed and provided to the Director. No deficiencies were cited during today's investigation.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Josiah Gathing
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2024
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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