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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
347005688
Report Date:
01/16/2020
Date Signed:
01/26/2021 09:33:49 AM
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
2525 NATOMAS PARK DR. STE.270
SACRAMENTO
,
CA
95833
FACILITY NAME:
FAIR OAKS CARE HOME
FACILITY NUMBER:
347005688
ADMINISTRATOR:
ANA, OTNIEL
FACILITY TYPE:
740
ADDRESS:
5121 ARROYO STREET
TELEPHONE:
(916) 966-6537
CITY:
FAIR OAKS
STATE:
CA
ZIP CODE:
95628
CAPACITY:
6
CENSUS:
85
DATE:
01/16/2020
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
03:30 PM
MET WITH:
n/a
TIME COMPLETED:
04:15 PM
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This report has been amended on 1/26/2021 by Licensing Program Analyst (LPA) Wolter due to being created on the wrong facility. Original report was not related to the facility listed.
SUPERVISOR'S NAME:
Laura Munoz
TELEPHONE:
(916) 263-4813
LICENSING EVALUATOR NAME:
Danyle Wolter
TELEPHONE:
(510) 298-7052
LICENSING EVALUATOR SIGNATURE:
DATE:
01/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/16/2020
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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