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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000731
Report Date: 01/31/2024
Date Signed: 01/31/2024 02:16:41 PM

Document Has Been Signed on 01/31/2024 02:16 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:DOSTY'S PRIVATE IN CARE SERVICE IIIFACILITY NUMBER:
347000731
ADMINISTRATOR:CAROLYN J. DOSTYFACILITY TYPE:
735
ADDRESS:2041 50TH AVENUETELEPHONE:
(916) 399-0408
CITY:SACRAMENTOSTATE: CAZIP CODE:
95822
CAPACITY: 6CENSUS: 4DATE:
01/31/2024
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
02:09 PM
MET WITH:Tameka CrawfordTIME COMPLETED:
02:45 PM
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On 1/31/24 at 1:40pm Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced collateral inspection at Dosty's Private Incare Service to address possible concerns regarding complaint #27-AS-20240119163445. LPA met with staff member Tameka Crawford.

LPA conducted interviews with one staff member.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2024
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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