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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 553601807
Report Date: 10/01/2019
Date Signed: 10/01/2019 01:28:12 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:MCKAY, SUSANFACILITY NUMBER:
553601807
ADMINISTRATOR:MCKAY, SUSANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 533-2871
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY:14CENSUS: 6DATE:
10/01/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Susan McKayTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Justin Denton met with Licensee Susan McKay for the regarding an incident reported on 9/30/19. During the visit, LPA interviewed Licensee McKay about the incident.

There were no Title 22 deficiencies issued at this time.

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

DATE: 09/30/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2019
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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