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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920076
Report Date: 08/08/2024
Date Signed: 08/08/2024 10:22:58 AM

Document Has Been Signed on 08/08/2024 10:22 AM - 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:JONATHAN VILLAFACILITY NUMBER:
345920076
ADMINISTRATOR/
DIRECTOR:		DUMUK, ROMANOFACILITY TYPE:
735
ADDRESS:7728 BLACK SAND WAYTELEPHONE:
(650) 703-1217
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 4CENSUS: 4DATE:
08/08/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Administrator- Romano & Ivy DumukTIME VISIT/
INSPECTION COMPLETED:
09:30 AM
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On 08/08/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct an annual required and post licensing visit. LPA met with Administrators Romano & Ivy Dumuk and explained the purpose of the visit.

For more information on the post licensing visit, please see LIC809 for Required - 1 Year dated 08/08/24.

No deficiencies cited for the post licensing visit.

Exit interview conducted a copy of the report was left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024
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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