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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393607983
Report Date: 12/31/2019
Date Signed: 12/31/2019 09:50:50 AM

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:SMITH, GLORIAFACILITY NUMBER:
393607983
ADMINISTRATOR:SMITH, GLORIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 956-9334
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY:14CENSUS: 6DATE:
12/31/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Gloria SmithTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Justin Denton conducted an unannounced inspection at the facility and met with Licensee Gloria Smith. The purpose of the inspection was to interview Licensee Smith about an incident that occurred at another facility.

No Title 22 deficiencies were issued at this time.

Notice of Site Visit posted and Appeal Rights provided.
SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Justin L DentonTELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:

DATE: 12/31/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2019
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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