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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920188
Report Date: 08/01/2024
Date Signed: 08/01/2024 11:30:29 AM

Document Has Been Signed on 08/01/2024 11:30 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:HOPEFUL HAVEN CARE HOME LLCFACILITY NUMBER:
315920188
ADMINISTRATOR/
DIRECTOR:		TARGA, CONCEPCIONFACILITY TYPE:
735
ADDRESS:1104 CEDAR DRIVETELEPHONE:
(530) 483-9133
CITY:WHEATLANDSTATE: CAZIP CODE:
95692
CAPACITY: 4CENSUS: 0DATE:
08/01/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Concepcion Targa and Jacob MeehanTIME VISIT/
INSPECTION COMPLETED:
11:40 AM
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Licensing Program Analysts (LPAs) Gunby and Hiratsuka, conducted this announced prelicensing visit. LPAs met with Applicants Concepcion Targa and Jacob Meehan.

This facility has a fire clearance for three ambulatory and one non-ambulatory for a total of four residents. There is a ramp for the front door. The front door enters into a hallway that has four private resident rooms, laundry room, and two full shared bathrooms. There is a door leading to the garage in the hallway. At the end of the hallway leads to the main common area that has the kitchen, dining, and main sitting area. The staff room is in the back of the facility and has a full private bathroom. The kitchen has an oven/stove that locks when not in use. There are locked cabinets and drawers for medications and sharp objects. There are no sheds in the backyard.

Component III orientation was conducted.

This facility meets regulations. LPA is going to submit this report to the application specialist.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2024
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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