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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313601840
Report Date: 02/17/2023
Date Signed: 02/17/2023 10:52:28 AM


Document Has Been Signed on 02/17/2023 10:52 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833



FACILITY NAME:QUISHENBERY, CHERIFACILITY NUMBER:
313601840
ADMINISTRATOR:QUISHENBERY, CHERIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 645-2813
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:14CENSUS: 0DATE:
02/17/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Cheri QuishenberyTIME COMPLETED:
11:15 AM
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Licensing Program Analysts Amanda Blesi and Lea Habtom arrived to conduct the annual inspection. Upon arrival licensee states she does not have any children enrolled at this time and would like to go inactive. LPA provided the Request to Go Inactive form LIC 9211. No annual inspection was conducted today. No children were observed in care. LPA will change the status to inactive upon return to the office.

Notice of site visit provided
Exit interview conducted.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amanda BlesiTELEPHONE: (916) 208-3427
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2023
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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