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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425203
Report Date: 04/11/2023
Date Signed: 04/11/2023 01:03:13 PM

Document Has Been Signed on 04/11/2023 01:03 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:MCCOLLUM'S HOPE RANCHFACILITY NUMBER:
366425203
ADMINISTRATOR:GOUCHER, KATHYFACILITY TYPE:
735
ADDRESS:589 FERN DRIVETELEPHONE:
(909) 336-9710
CITY:TWIN PEAKSSTATE: CAZIP CODE:
92391
CAPACITY: 6CENSUS: 3DATE:
04/11/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:53 PM
MET WITH:Kathy GoucherTIME COMPLETED:
01:05 PM
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Licensing Program Analysts (LPAs) Anna Bueno and Rayshaun Nickolas conducted an unannounced visit to the facility to deliver an amended annual inspection report originally conducted on 9/18/2022 that focused on infection control measures.

No deficiencies cited during today's visit and a copy of this report was provided to Mrs. Goucher.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2023
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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