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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
392700729
Report Date:
02/17/2022
Date Signed:
02/17/2022 02:43:59 PM
Document Has Been Signed on
02/17/2022 02:43 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
,
2525 NATOMAS PARK DR. STE.270
SACRAMENTO
,
CA
95833
FACILITY NAME:
YANNICA GUEST HOME
FACILITY NUMBER:
392700729
ADMINISTRATOR:
MARTIN, MAXIMA
FACILITY TYPE:
740
ADDRESS:
2329 DIAMOND OAKS STREET
TELEPHONE:
(510) 366-6585
CITY:
STOCKTON
STATE:
CA
ZIP CODE:
95206
CAPACITY:
6
CENSUS:
4
DATE:
02/17/2022
TYPE OF VISIT:
Post Licensing
UNANNOUNCED
TIME BEGAN:
01:43 PM
MET WITH:
Staff
TIME COMPLETED:
01:59 PM
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The Post licensing visit is included in the Annual Report for today's inspection.
SUPERVISOR'S NAME:
Stephenie Doub
TELEPHONE:
(916) 263-2131
LICENSING EVALUATOR NAME:
Albert Johnson
TELEPHONE:
(916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE:
02/17/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/17/2022
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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