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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 293623223
Report Date: 03/14/2024
Date Signed: 03/14/2024 12:22:29 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/14/2024 12:22 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:KEMPLIN, BETHFACILITY NUMBER:
293623223
ADMINISTRATOR:KEMPLIN, BETHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 205-9608
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
03/14/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Beth KemplinTIME COMPLETED:
12:30 PM
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On 3/14/2024, Licensing Program Analyst (LPA) Matthew Gallo met with licensee Beth Kemplin for the purpose of a required 1-year annual visit. Upon arrival, licensee informed LPA that they have closed their day care and are no longer operational. LPA observed no children in care. Licensee relinquished physical license to LPA, and acknowledged that by signing this form, they agree to forfeit their license.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Matthew Gallo
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2024
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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