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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003969
Report Date: 02/05/2025
Date Signed: 02/05/2025 09:45:37 AM

Document Has Been Signed on 02/05/2025 09:45 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:DAVID FAMILY HOMEFACILITY NUMBER:
347003969
ADMINISTRATOR/
DIRECTOR:		DAVID, LIZAFACILITY TYPE:
740
ADDRESS:4741 PISMO BEACH DRIVETELEPHONE:
(916) 745-3626
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
02/05/2025
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Administrator- Liza David TIME VISIT/
INSPECTION COMPLETED:
09:50 AM
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Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility announced on 02/05/2025 to conduct a Required 1- Year Inspection utilizing the care tool. This was a planned visit due to facility not having any residents. LPA met with Administrator, Liza David. Administrator Certificate is current with an expiration date of 05/18/2026.

LPA and Administrator conducted a tour of the facility. Area toured included but not limited to the kitchen, dining room, bedrooms and bathrooms, common areas, and backyard. LPA observed sufficient furniture and lighting throughout the facility. Facility has locked cabinets for knives and medications. Hot water temperature was measured at 116.2 degrees Fahrenheit in the kitchen sink which is within the required range of 105 to 120 degrees. LPA observed smoke detectors and carbon monoxide detectors to be operable.

Currently there are no residents living in facility; and have never been any. Facility is being lived in by Administrator Liza David and her mother, Luisa David. Facility has plans to start accepting residents. Administrator will let LPA Ratajczak know when they have their first resident.

No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of report left at the facility.
Laura MunozTELEPHONE: (916) 263-4743
Cheyenne RatajczakTELEPHONE: (916) 969-7879
DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2025
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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