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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390307976
Report Date: 10/04/2023
Date Signed: 10/04/2023 10:51:21 AM

Document Has Been Signed on 10/04/2023 10:51 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:WEST VALLEY CHRISTIAN ACADEMY PRESCHOOLFACILITY NUMBER:
390307976
ADMINISTRATOR:MICHELE SMITHFACILITY TYPE:
850
ADDRESS:1790 SEQUOIA BOULEVARDTELEPHONE:
(209) 835-2783
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY: 108TOTAL ENROLLED CHILDREN: 72CENSUS: 63DATE:
10/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH:Michele Smith TIME COMPLETED:
10:50 AM
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On October 4, 2023, Licensing Program Analyst (LPA) Stacey Williams conducted a case management inspection and met with Director, Michele Smith. LPA toured the facility and observed (63) sixty three children supervised by ten staff ( 4 classrooms ).

LPA discussed the unusual incident reports submitted to Community Care Licensing on September 26th and 27th, 2023.

No title 22 deficiencies were cited during today's inspection.

Exit interview conducted and report was reviewed with the Director, Michele Smith. A notice of site visit was given 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: Stacey Williams
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2023
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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