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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701273
Report Date: 11/26/2024
Date Signed: 11/26/2024 03:26:30 PM

Document Has Been Signed on 11/26/2024 03:26 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:DA VINCI HOUSEFACILITY NUMBER:
392701273
ADMINISTRATOR/
DIRECTOR:		BOYD, JAMESHAFACILITY TYPE:
735
ADDRESS:4511 DA VINCI DRTELEPHONE:
(510) 815-8570
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 4CENSUS: 3DATE:
11/26/2024
TYPE OF VISIT:CollateralUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:21 PM
MET WITH:Jamesha BoydTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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On 11-26-24 at 2:21pm, Licensing Program Analyst (LPA) Michael Bilger arrived to conduct a collateral visit regarding resident1 (R1) and a previous incident which occurred at facility LIC. #397005738. LPA met with Administrator Jamesha Boyd and explained the purpose of the visit. LPA conducted interview with R1 as part of today's visit regarding the incident as noted above.

An exit interview was conducted with Administrator and a copy of this report was provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2024
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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