<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397203027
Report Date: 04/02/2024
Date Signed: 04/02/2024 04:45:36 PM

Document Has Been Signed on 04/02/2024 04:45 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: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:
04/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Mandy WittherTIME COMPLETED:
04:55 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 4/2/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required one year annual inspection. LPA Jensen met with house manager Mandy Witther and explained the purpose of today's visit. The Administrator holds a current certification good through 3/31/2025.

There are currently 6 consumers. LPA Jensen toured the interior of the facility. The facility was observed to be sanitary. All cleaning supplies, medications and knives were observed to be locked with a mechanism operated by fingerprints. The first aid kit was observed to be complete. The smoke detector and carbon monoxide detector were tested and found to be in good repair. The fire extinguisher was last serviced in October of 2023 and is in compliance. LPA Jensen observed a 2 day supply of perishable food and a 7 day supply of non-perishable food. All food removed from original packaging was labeled.

This annual inspection will require additional time to complete.

An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1