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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
342701317
Report Date:
02/08/2024
Date Signed:
02/08/2024 09:41:07 AM
Document Has Been Signed on
02/08/2024 09:41 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 SOUTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
TAMBOR HOME
FACILITY NUMBER:
342701317
ADMINISTRATOR:
VERGARA, RICHARD CARLSON
FACILITY TYPE:
735
ADDRESS:
8458 TAMBOR WAY
TELEPHONE:
(916) 577-5770
CITY:
ELK GROVE
STATE:
CA
ZIP CODE:
95758
CAPACITY:
3
CENSUS:
0
DATE:
02/08/2024
TYPE OF VISIT:
Prelicensing
ANNOUNCED
TIME BEGAN:
09:00 AM
MET WITH:
Richard Vergara
TIME COMPLETED:
09:50 AM
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Licensing Program Analyst (LPA) Vincent Moleski arrived announced to conduct a follow-up prelicensing visit. LPA Moleski met with applicant Richard Vergara and explained the purpose of the visit.
LPA Moleski toured the facility with Vergara and observed that all deficiencies noted on LPA Moleski's previous report were corrected. LPA Moleski has no objections to licensure at this time. An exit interview was held and a copy of this report was left with Vergara.
SUPERVISORS NAME
:
Stephen Richardson
LICENSING EVALUATOR NAME
:
Vincent Moleski
LICENSING EVALUATOR SIGNATURE
:
DATE:
02/08/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/08/2024
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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