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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340314399
Report Date: 10/03/2022
Date Signed: 10/17/2022 03:22:51 PM

Document Has Been Signed on 10/17/2022 03:22 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
Lookup Error,
, CA
FACILITY NAME:DOSTY'S PRIVATE INCARE SERVICEFACILITY NUMBER:
340314399
ADMINISTRATOR:JANAE ROSSFACILITY TYPE:
735
ADDRESS:7093 CROMWELL WAYTELEPHONE:
(916) 399-1365
CITY:SACRAMENTOSTATE: CAZIP CODE:
95822
CAPACITY: 6CENSUS: 4DATE:
10/03/2022
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Janae Ross, AdministratorTIME COMPLETED:
01:15 PM
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On 10/3/2022 LPA Tryon visited Dosty's Private Incare Service to do a COLLATERAL visit to speak with a new resident who moved into the facility recently. This visit was in relation to another facility, and has NOTHING to do with Dosty's Private Incare Service.

LPA spoke with staff and resident involved.

No deficiencies cited at this visit. Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2022
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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