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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
392700644
Report Date:
06/14/2021
Date Signed:
02/16/2022 12:09:55 PM
Document Has Been Signed on
02/16/2022 12:09 PM
- It Cannot Be Edited
Document is an Amendment of
Original Document
on
11/23/2021 01:16 PM
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
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The Post licensing visit was completed.
LPA reviewed staff and residents records the records were complete.
No deficiencies for the post licensing visit.
SUPERVISOR'S NAME:
Stephenie Doub
TELEPHONE:
(916) 263-2131
LICENSING EVALUATOR NAME:
Albert Johnson
TELEPHONE:
(916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE:
06/14/2021
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/14/2021
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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