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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343604900
Report Date: 09/11/2019
Date Signed: 09/11/2019 01:02:00 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:4TH R - PHOEBE HEARSTFACILITY NUMBER:
343604900
ADMINISTRATOR:NOLLER, CHRISTINEFACILITY TYPE:
840
ADDRESS:1410 60TH STREETTELEPHONE:
(916) 277-3840
CITY:SACRAMENTOSTATE: CAZIP CODE:
95819
CAPACITY:170CENSUS: 0DATE:
09/11/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Lori WeberTIME COMPLETED:
01:15 PM
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Licensing Program Analysts (LPAs) Marea Behvand and Seychelle De Luca met with Program Developer Lori Weber for an unannounced case management inspection to discuss the unusual incident report (UIR) that the program submitted on 09/10/2019 and which occurred on 09/09/2019. Present were three staff members. LPAs interviewed staff and toured the facility indoors.

In the areas that were evaluated, no deficiencies were observed at the time of the visit. An exit interview was conducted and a Notice of Site Visit was posted.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Marea BehvandTELEPHONE: (916) 216-7793
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2019
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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