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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
397203028
Report Date:
06/21/2023
Date Signed:
08/04/2023 05:48:02 PM
Document Has Been Signed on
08/04/2023 05:48 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 AC/SC
,
2525 NATOMAS PARK DR. STE.270
SACRAMENTO
,
CA
95833
FACILITY NAME:
MARCI MEDINA'S CARE HOME
FACILITY NUMBER:
397203028
ADMINISTRATOR:
MEDING, CINDY R.
FACILITY TYPE:
735
ADDRESS:
2449 NEW BRIGHTON LANE
TELEPHONE:
(209) 451-1158
CITY:
STOCKTON
STATE:
CA
ZIP CODE:
95209
CAPACITY:
6
CENSUS:
DATE:
06/21/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:47 AM
MET WITH:
TIME COMPLETED:
09:48 AM
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SUPERVISORS NAME
:
Liza King
LICENSING EVALUATOR NAME
:
Kesha Lewis
LICENSING EVALUATOR SIGNATURE
:
DATE:
06/21/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/21/2023
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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