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

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 234700001
Report Date: 10/25/2022
Date Signed: 10/25/2022 04:34:31 PM

Document Has Been Signed on 10/25/2022 04:34 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
CCLD Regional Office, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
FACILITY NAME:GOERTZEN CARE DBA ANDERSSON CAREFACILITY NUMBER:
234700001
ADMINISTRATOR:AARON GOERTZENFACILITY TYPE:
300
ADDRESS:32924 ODOM LANETELEPHONE:
(707) 964-4040
CITY:FORT BRAGGSTATE: CAZIP CODE:
95437
CAPACITY: CENSUS: DATE:
10/25/2022
Annual/RequiredUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Aaron GoertzenTIME COMPLETED:
04:30 PM
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
Home Care Services Bureau (HCSB) analyst Ramsey Chimienti arrived at the business office of ANDERSSON CARE on 10/25/2022. Upon arrival, the HCSB analyst identified himself and was greeted by Aaaron Goertzen. The proper posting of business hours and license was observed. 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 Aaron and informed the Licensee that no discrepancies were found. In addition, the Licensee was provided a printed copy of the LIC 9058 (Applicant/Licensee Rights) form.
LICENSING EVALUATOR NAME: Ramsey Chimienti
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

HCS809 (FAS) - (06/04)
Page: 1 of 1