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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345003004
Report Date: 05/29/2024
Date Signed: 05/29/2024 01:51:04 PM


Document Has Been Signed on 05/29/2024 01:51 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:LITTLE BROOK CARE HOMEFACILITY NUMBER:
345003004
ADMINISTRATOR:POP, PERSIDAFACILITY TYPE:
740
ADDRESS:8832 FAIR OAKS BLVDTELEPHONE:
(279) 289-6907
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 5DATE:
05/29/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Persida Pop, AdministratorTIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Angela Hood arrived unannounced at the facility today, 5/29/24, and met with Administrator, Persida Pop, to follow-up on five plan of corrections made to the facility on 5/23/24 to be corrected on 5/24/24.

Plan of corrections were not received by 5/24/24. As a result of this visit, civil penalties in the amount of $2,500 were assessed because the facility did not comply with a plan of corrections for the time period of 5/24/24 thru 5/29/24.

Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. Administrator's signature on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
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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