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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397203027
Report Date: 07/29/2022
Date Signed: 07/29/2022 12:55:29 PM

Document Has Been Signed on 07/29/2022 12:55 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:WYCOFF FAMILY CARE HOMEFACILITY NUMBER:
397203027
ADMINISTRATOR:WYCOFF, STACYFACILITY TYPE:
735
ADDRESS:3908 SETROK COURTTELEPHONE:
(209) 996-4487
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 6CENSUS: 6DATE:
07/29/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:House Manager, Mandy Witthar TIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit to the facility July 29, 2022 at 11:45 a.m. to conduct a Case Management visit. LPA met with House Manager, Mandy Witthar and explained the purpose of the visit.

LPA received notification that Staff 1's background appeal was denied. LPA informed the facility Staff 1 is not to be working at the facility as he is no longer considered background cleared.


No deficiencies were cited during todays visit.

Exit interview conducted with facility staff Mandy Witthar.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2022
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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