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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700787
Report Date: 11/29/2021
Date Signed: 11/29/2021 12:40:14 PM

Document Has Been Signed on 11/29/2021 12:40 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:LIBBIE CARE HOMEFACILITY NUMBER:
392700787
ADMINISTRATOR:RAM, AVINESHFACILITY TYPE:
735
ADDRESS:558 E EDISON STTELEPHONE:
(209) 824-5993
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY: 5CENSUS: 3DATE:
11/29/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Avinesh RamTIME COMPLETED:
11:15 AM
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LPA Albert Johnson made an unannounced POC visit to the facility to verify correction of citation issued during the Annual inspection on 10/26/2021.

Deficiency cited under Title 22 Regulations have been cleared. Licensee complied with the terms of the POC by POC due date.

Facility was provided POC cleared letter.

Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2021
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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