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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
345002938
Report Date:
12/07/2023
Date Signed:
12/07/2023 01:03:46 PM
Document Has Been Signed on
12/07/2023 01:03 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:
COZY HOME CARE
FACILITY NUMBER:
345002938
ADMINISTRATOR:
BRIONES, AIDA R.
FACILITY TYPE:
740
ADDRESS:
5643 CLARK AVE.
TELEPHONE:
(916) 283-4142
CITY:
CARMICHAEL
STATE:
CA
ZIP CODE:
95608
CAPACITY:
6
CENSUS:
6
DATE:
12/07/2023
TYPE OF VISIT:
Post Licensing
UNANNOUNCED
TIME BEGAN:
12:47 PM
MET WITH:
Aida Briones
TIME COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a required annual inspection. LPA met with Administrator Aida Briones 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 was provided.
SUPERVISOR'S NAME:
Anthony Perez
TELEPHONE:
(323) 485-4915
LICENSING EVALUATOR NAME:
Cassie Yang
TELEPHONE:
916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE:
12/07/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/07/2023
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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