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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700808
Report Date: 11/14/2024
Date Signed: 11/14/2024 12:17:12 PM

Document Has Been Signed on 11/14/2024 12:17 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PACIFIC COAST CARE HOMESFACILITY NUMBER:
312700808
ADMINISTRATOR/
DIRECTOR:		ZAIDI, MARIAFACILITY TYPE:
740
ADDRESS:4470 ROLLING OAKS DRIVETELEPHONE:
(916) 823-3902
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY: 6CENSUS: 0DATE:
11/14/2024
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Caregiver-Alexander VelezTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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On 11/14/24 Licensing Program Analysts (LPA) Graham Gunby and Cheyenne Ratajczak met with caregiver, Alexander Velez to conduct an inspection proceeding the closure of the facility. The facility had no residents upon sending Notice of Facility Closure to Regional Office.

LPA observed interior/exterior of the facility, including front and back yard, common areas, dining room and kitchen area, closets, laundry room, 2 bathrooms, and 5 bedrooms. LPAs observed that there were no residents at the facility.

LPA informed Licensee that facility will be closed in the department's system effective today, 11/14/2024.

Exit interview was conducted with Alexander and a copy of this report was provided to the licensee.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Graham Gunby
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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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