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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 344500641
Report Date: 02/23/2023
Date Signed: 02/23/2023 11:14:31 AM

Document Has Been Signed on 02/23/2023 11:14 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 SOUTH, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:CATALYST KIDS - MIWOK VILLAGEFACILITY NUMBER:
344500641
ADMINISTRATOR:TRIGGS, MARIAFACILITY TYPE:
840
ADDRESS:10070 LOUSADA DRIVETELEPHONE:
(916) 686-6495
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 70TOTAL ENROLLED CHILDREN: 70CENSUS: 16DATE:
02/23/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Maria TriggsTIME COMPLETED:
11:30 AM
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On 2/23/23 Licensing Program Analyst Corina Beckby (LPA1) and Licensing Program Analyst Katy Maestas (LPA2) conducted a Case Management Inspection for the purpose of following-up on an Unusual Incident Report that was submitted to the Regional Office on 02/15/2023. LPA1 and LPA2 arrived at the facility and was granted entrance. LPA's met with Program Lead, Maria Triggs (P1).Upon arrival, the facility had 3 staff members supervising 16 school age children. LPA's verified that all adults were cleared and associated to the license through accessing Guardian. LPA1 requested a copy of the Facility Roster and conducted interviews. LPA's reviewed information that was pertinent to the unusual incident which occurred on 02/14/2023.

An exit interview was conducted with P1 in which the Facility Evaluation Report was reviewed. In the areas that were inspected today on 02/23/23, no deficiencies were cited. A Notice of Site Visit was posted by LPA and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Corina Beckby
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2023
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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