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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003969
Report Date: 01/04/2024
Date Signed: 01/04/2024 10:05:08 AM


Document Has Been Signed on 01/04/2024 10:05 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:DAVID, LIZAFACILITY TYPE:
740
ADDRESS:4741 PISMO BEACH DRIVETELEPHONE:
(916) 745-3626
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY:6CENSUS: 0DATE:
01/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator- Liza David TIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced on 01/04/24 to conduct a Required 1- Year Inspection utilizing the care tool. LPA met with administrator, Liza David, and explained the purpose of the visit.

LPA and Administrator conducted a tour of the facility. Area toured included but not limited to the kitchen, dining room, bedrooms and bathrooms, medication cabinet, and backyard. LPA observed sufficient furniture and lighting throughout the facility. Hot water temperature was measured at 115 degrees Fahrenheit in the kitchen sink which is within the required range of 105 to 120 degrees. Fire extinguishers and smoke detectors are current and in compliance with fire safety including carbon monoxide detector.

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 this year. Administrator will let LPA Ratajczak know when they have their first consumer.

Administrator requested referral for the Technical assistance program. LPA provided Administrator with LIC311F.

The administrator will send LPA Ratajczak a copy of the current liability insurance and copy of current Administrator’s Certificate to update the facility file.

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

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2024
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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