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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 194700756
Report Date: 05/16/2024
Date Signed: 05/16/2024 02:56:32 PM

Document Has Been Signed on 05/16/2024 02:56 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
HOME CARE SERVICES, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
FACILITY NAME:EXTRAORDINARY HOLDINGS CORP.FACILITY NUMBER:
194700756
ADMINISTRATOR/
DIRECTOR:		STEVEN NICKENS SRFACILITY TYPE:
300
ADDRESS:4501 CERRITOS AVETELEPHONE:
(562) 900-7845
CITY:CYPRESSSTATE: CAZIP CODE:
90630
CAPACITY: CENSUS: DATE:
05/16/2024
Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Steven Nickens, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Home Care Services Bureau (HCSB) Analyst, Mila Quinto arrived at the business office of EXTRAORDINARY HOLDINGS CORP for a post licensing inspection. Upon arrival, Analyst Quinto was greeted by Licensee, Steven Nickens and Designee, Kim Perata. The proper posting of business hours and license was observed. The proof of insurance's record was reviewed. The Analyst was then shown to an area where the review of personnel and administrative files could be performed. Upon completion of the file review the analyst discussed the findings of the inspection with Licensee and designee and informed that no discrepancies were found.
LICENSING EVALUATOR NAME: Mila Quinto
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

HCS809 (FAS) - (06/04)
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