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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
405801779
Report Date:
01/17/2020
Date Signed:
02/02/2023 03:05:10 PM
Document Has Been Signed on
02/02/2023 03:05 PM
- It Cannot Be Edited
Document is an Amendment of
Original Document
on
02/05/2020 01:15 PM
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
6500 HOLLISTER AVE. SUITE 200
GOLETA
,
CA
93117
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SUPERVISOR'S NAME:
Jeralyn Ann Pfannenstiel
TELEPHONE:
(818) 596-4343
LICENSING EVALUATOR NAME:
Mark Jeffries
TELEPHONE:
(805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE:
02/07/2020
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/07/2020
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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