<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624918
Report Date: 04/11/2024
Date Signed: 04/11/2024 03:23:12 PM

Document Has Been Signed on 04/11/2024 03:23 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:
343624918
ADMINISTRATOR/
DIRECTOR:		CHRISTINA DIAZ BUSHMANFACILITY TYPE:
840
ADDRESS:2433 MISSION AVENUETELEPHONE:
(916) 276-0279
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 18TOTAL ENROLLED CHILDREN: 18CENSUS: 0DATE:
04/11/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Nicole Moran-EstradaTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On April 11, 2024 at approximately 1:30 PM Licensing Program Analyst (LPA) Josiah Gathing met with Director Nicole Moran-Estrada to investigate a self-reported Unusual incident that occurred on March 27, 2024. LPA's investigation did not reveal any violation of Licensing regulation and no citations were issued during today's inspection.

A copy of this report was printed and provided to the Director.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Josiah Gathing
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1