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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700105
Report Date: 09/08/2023
Date Signed: 09/08/2023 10:53:56 AM

Document Has Been Signed on 09/08/2023 10:53 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:NAOMI GUEVARRA RESIDENTIALFACILITY NUMBER:
342700105
ADMINISTRATOR:GUEVARRA, NAOMIFACILITY TYPE:
735
ADDRESS:8186 LAGUNA BROOK WAYTELEPHONE:
(650) 580-8857
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 4CENSUS: 4DATE:
09/08/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Arnel GuevarraTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski spoke with administrator Naomi Guevarra over the phone and explained the purpose of the visit.
This facility received a new fire clearance on 8/28/23. LPA Moleski collected this facility's old license and printed out a new license reflective of the facility's new capacity.

No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Guevarra.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2023
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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