Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343603166
Report Date: 01/09/2018
Date Signed 01/09/2018 12:08:59 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:ELK GROVE SCHOOL AGE CDCFACILITY NUMBER:
343603166
ADMINISTRATOR:MONICA CHANEYFACILITY TYPE:
840
ADDRESS:9373 CROWELL DRIVETELEPHONE:
(916) 686-6495
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:70CENSUS: 5DATE:
01/09/2018
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Monica Chaney - Director TIME COMPLETED:
12:15 PM
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An unannounced inspection was conducted today by Licensing Program Analyst Owens. LPA Owens met with Site Supervisor Monica Chaney. The purpose of the inspection is to interview a child on a complaint unrelated to this facility.

No deficiencies
SUPERVISOR'S NAME: Jennifer BrekkeTELEPHONE: (916) 263-5717
LICENSING EVALUATOR NAME: Katrina OwensTELEPHONE: 916-263-6280
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2018
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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