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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700835
Report Date: 11/23/2020
Date Signed: 11/23/2020 12:45:24 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 744 P STREET, MS 8-3-91
SACRAMENTO, CA 95814
FACILITY NAME:CITY CREEK ASSISTED LIVINGFACILITY NUMBER:
342700835
ADMINISTRATOR:CUMMIE, BRIDGETFACILITY TYPE:
740
ADDRESS:6254 66TH AVENUETELEPHONE:
(408) 741-2950
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:121CENSUS: DATE:
11/23/2020
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ryan Williams and Bridget CummieTIME COMPLETED:
10:30 AM
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COMP II by CAB successfully completed
Facility Type: RCFE
Application Type: CHOW
Capacity:121
Census: Avg 98
Method: Telephone call with CAB Analyst
COMP II Participants: Ryan Williams, Applicant and Bridget Cummie, Administrator

Ryan Williams and Bridget Cummie participated in COMP II via telephone call with analyst Kathleen Carroll at CAB. Identification of Ryan Williams and Bridget Cummie were verified by photo ID that was submitted with the application. During COMP II,Ryan Williams and Bridget Cummie confirmed the understanding of Title 22. Component II was successfully completed. Ryan Williams and Bridget Cummie have been advised to transmit signed LIC 809 to CAB.
SUPERVISOR'S NAME: Julia KimTELEPHONE: (916) 651-7848
LICENSING EVALUATOR NAME: Kathleen CarrollTELEPHONE: (916) 651-3129
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2020
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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