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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 344700099
Report Date: 12/06/2021
Date Signed: 12/06/2021 12:09:06 PM

Document Has Been Signed on 12/06/2021 12:09 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
FACILITY NAME:ALERT SHACK LLCFACILITY NUMBER:
344700099
ADMINISTRATOR:WITTKOPP, MARKFACILITY TYPE:
300
ADDRESS:1024 IRON POINT RDTELEPHONE:
(650) 996-4052
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY: 0CENSUS: DATE:
12/06/2021
Case Management - Biennial Required ContinuationUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Maira Lopez & Mark WittkoppTIME COMPLETED:
12:15 PM
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Home Care Services Bureau (HCSB) Ramsey Chimienti arrived at the business office of Alert Shack LLC on 12/6/2021. Upon arrival, the HCSB analyst identified himself and was greeted by Licensees Maira Lopez and designee Mark Wittkopp. The proper posting of business hours and license was observed. The analyst was then shown to an area where the review of personnel and administrative files could be performed. Upon completion of the file review the analyst discussed the findings of the inspection with the Licensee and Designee and informed that that no discrepancies were found.
LICENSING EVALUATOR NAME: Ramsey Chimienti
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

HCS809 (FAS) - (06/04)
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