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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 283009661
Report Date: 11/20/2019
Date Signed: 11/20/2019 10:06:47 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:NORES, BRIDGET FCCHFACILITY NUMBER:
283009661
ADMINISTRATOR:NORES, BRIDGETFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 432-8943
CITY:AMERICAN CANYONSTATE: CAZIP CODE:
94503
CAPACITY:14CENSUS: 5DATE:
11/20/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Bridget NoresTIME COMPLETED:
10:20 AM
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LPA Kevin O'Connell made an unannounced inspection to conduct a Confirmation of Removal visit to verify that the Licensee's Fiance is not present and not residing at the facility.
The Individual was not present at the facility at the time of the inspection and has not been present at any of the past inspections. The Licensee states that her Fiance is not residing at the home and will not until told to do so.
I have confirmed that he is removed as of today. The Licensee is moving forward with the appeal process. A follow up inspection may be needed at some time in the future.

No title 22 deficiencies were cited today.
A Notice of Site Visit shall be posted for 30 days from today's visit.

SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Kevin O'ConnellTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2019
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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