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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804258
Report Date: 08/05/2024
Date Signed: 09/18/2024 03:21:39 PM

Document Has Been Signed on 09/18/2024 03:21 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRALIZED APP UNIT, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:HAYES HOUSEFACILITY NUMBER:
216804258
ADMINISTRATOR/
DIRECTOR:		SCUTT, JACQUES PFACILITY TYPE:
735
ADDRESS:5 HAYES STTELEPHONE:
(415) 847-2087
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 6CENSUS: 0DATE:
08/05/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Jacques ScuttTIME VISIT/
INSPECTION COMPLETED:
09:30 AM
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Component II completion: Successful

Facility Type: ARF
Application Type: INTL
Capacity: 6
Census : 0
Method: Telephone call with CAB
COMP II Participants: Jacques Scutt (Administrator/Licensee) & Tammy Edwards (Analyst).

Administrator/Licensee participated in COMP II via telephone call with CAB analyst. Identification of the Administrator/Licensee was verified by confirming driver’s license number. During COMP II, Administrator/Licensee confirmed the understanding of Title 22. Component II was successfully completed. Administrator/Licensee was advised to email signed LIC 809 with copy of photo ID to CAB.

During COMP II, CAB analyst confirmed Administrator/Licensee's understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Tammy Edwards
LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2024
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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