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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 053621738
Report Date: 05/14/2019
Date Signed: 05/14/2019 02:26:16 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:VOLLSTEDT, ELOISEFACILITY NUMBER:
053621738
ADMINISTRATOR:VOLLSTEDT, ELOISEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 269-0517
CITY:VALLEY SPRINGSSTATE: CAZIP CODE:
95252
CAPACITY:14CENSUS: 8DATE:
05/14/2019
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Eloise VollstedtTIME COMPLETED:
02:45 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
LPA Denton made unannounced visit to verify correction of deficiency cited on previous visit. LPA met with licensee, Eloise Vollstedt.

The following deficiency was cited during visits conducted 4/30/19:
*102417(g)(4) Operation of a Family Care Home.

Upon arrival to the home, LPA observed ammunition and firearms properly stored as required by Title 22 regulation.

No Title 22 deficiencies cited during today's visit.

Notice of site visit posted.

Exit interview conducted.
SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Justin L DentonTELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2019
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