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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
345002859
Report Date:
09/10/2024
Date Signed:
09/10/2024 01:30:55 PM
Document Has Been Signed on
09/10/2024 01:30 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
SACRAMENTO NORTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
MOAI
FACILITY NUMBER:
345002859
ADMINISTRATOR:
FOWLER, CRAIG M.
FACILITY TYPE:
740
ADDRESS:
2633 CARDINAL COURT
TELEPHONE:
(916) 844-5250
CITY:
CARMICHAEL
STATE:
CA
ZIP CODE:
95608
CAPACITY:
5
CENSUS:
2
DATE:
09/10/2024
TYPE OF VISIT:
Post Licensing
UNANNOUNCED
TIME BEGAN:
01:11 PM
MET WITH:
Craig Fowler
TIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a required annual inspection. LPA met with Licensee/Administrator and explained the purpose of the visit
LPA is conducting an annual inspection today but this report is being generated to clear the Post-Licensing inspection in the system.
There are no citations issued on this report.
Exit interview. Copy of report provided.
SUPERVISOR'S NAME:
Anthony Perez
TELEPHONE:
(323) 485-4915
LICENSING EVALUATOR NAME:
Cassie Yang
TELEPHONE:
(916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE:
09/10/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/10/2024
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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