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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920046
Report Date: 08/05/2024
Date Signed: 08/05/2024 02:39:30 PM


Document Has Been Signed on 08/05/2024 02:39 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:SIGNATURE LIVING ON WINDING WAY IIIFACILITY NUMBER:
345920046
ADMINISTRATOR:AFABLE, SCOTTFACILITY TYPE:
740
ADDRESS:6264 WINDING WAYTELEPHONE:
(916) 952-4348
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 5DATE:
08/05/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Scott Afable and Placida DeveraTIME COMPLETED:
03:00 PM
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On 8/5/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a required annual inspection. LPA met with Caregiver, who then contacted 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 PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2024
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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