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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002046
Report Date: 09/07/2023
Date Signed: 09/07/2023 02:04:31 PM

Document Has Been Signed on 09/07/2023 02:04 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PEREGRINE HOMEFACILITY NUMBER:
455002046
ADMINISTRATOR:BRANSCOMB, KALEBFACILITY TYPE:
735
ADDRESS:1163 PEREGRINE WAYTELEPHONE:
(530) 262-0967
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY: 4CENSUS: 4DATE:
09/07/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Kaleb BranscombTIME COMPLETED:
02:41 PM
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On 09-07-23 Licensing Program Analyst Sarah Benson met with Kaleb Branscomb to review Amended Annual and Citation dated 06-23-23.

The Annual and citation were both signed and completed.

No deficiencies cited, facility is in compliance.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2023
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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