<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097001625
Report Date: 03/25/2022
Date Signed: 03/25/2022 09:54:36 AM


Document Has Been Signed on 03/25/2022 09:54 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:VALLEY VIEW GUEST HOMEFACILITY NUMBER:
097001625
ADMINISTRATOR:REBECA FRIENDFACILITY TYPE:
740
ADDRESS:891 OAK TERRACE ROADTELEPHONE:
(530) 626-6179
CITY:PLACERVILLESTATE: CAZIP CODE:
95667
CAPACITY:6CENSUS: 0DATE:
03/25/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Rebeca FriendTIME COMPLETED:
10:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensee initiated case management visit regarding closure of the facility. Licensee has decided to retire. Facility walk through visit revealed that there no residents in care. Effective 3/25/22 facility will be closed. Licensee surrendered the facility license. Upon return to the office, LPA will close the facility out in the main database.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Michael SmithTELEPHONE: (916) 208-7807
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1