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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
455002964
Report Date:
06/28/2023
Date Signed:
06/28/2023 12:39:42 PM
Document Has Been Signed on
06/28/2023 12:39 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:
CHURN CREEK BOTTOM
FACILITY NUMBER:
455002964
ADMINISTRATOR:
CURTIS, JEFFREY
FACILITY TYPE:
735
ADDRESS:
7149 CHURN CREEK ROAD
TELEPHONE:
(530) 782-2572
CITY:
REDDING
STATE:
CA
ZIP CODE:
96002
CAPACITY:
4
CENSUS:
4
DATE:
06/28/2023
TYPE OF VISIT:
Prelicensing
UNANNOUNCED
TIME BEGAN:
11:35 AM
MET WITH:
Jacobb Nuss
TIME COMPLETED:
12:55 PM
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On 6/28/2023 Licensing Program Analyst (LPA) Ivan Avila and Licensing Program Manager (LPM) Lauren Crocker arrived at the facility for a Pre-Licensing visit and met with Administrator Jacobb Nuss and explained the purpose of the visit. A tour of the facility took place. The facility has some areas under construction and a follow up meeting will be conducted to ensure the facility is ready to be licensed upon completion.
Department is waiving Component III. Administrator has existing facilities.
SUPERVISORS NAME
:
Lauren Crocker
LICENSING EVALUATOR NAME
:
Ivan Avila
LICENSING EVALUATOR SIGNATURE
:
DATE:
06/28/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/28/2023
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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