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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345003004
Report Date: 09/05/2024
Date Signed: 09/05/2024 12:28:16 PM


Document Has Been Signed on 09/05/2024 12:28 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: DATE:
09/05/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Persida PopTIME COMPLETED:
01:00 PM
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On 9/5/24, LPA Kevin Mknelly arrived unannounced to deliver amended complaint findings originally delivered 8/1/24.

LPA met with the administrator.

No additional citations are issued as the result of the visit.

Report reviewed and copy provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024
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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