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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700755
Report Date: 04/12/2022
Date Signed: 04/12/2022 02:47:20 PM


Document Has Been Signed on 04/12/2022 02:47 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:GABRIELLE'S CARING HANDFACILITY NUMBER:
502700755
ADMINISTRATOR:ANTONIO, MA TABITHAFACILITY TYPE:
740
ADDRESS:3109 WATERBURY CTTELEPHONE:
(408) 823-0358
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:6CENSUS: 5DATE:
04/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator Ma Tabitha AntonioTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Jason Lund arrived at the above address to conduct an unannounced annual/required visit. LPA met with Care staff and explained the purpose of the visit. Later Administrator Ma Tabitha Antonio joined the inspection.

LPA and Administrator Ma Tabitha Antonio walked the physical plant including but not limited to kitchen, bedrooms, bathrooms, living and dining room area. During the tour LPA observed the garage exit door blocked by shelves and boxes. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present in/or around the facility. LPA observed sufficient seven- day non-perishable and two- day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. Carbon dioxide monitor present

No feficiencies were observed and cited during this visit. Exit interview held and a report given at the conclusion of the visit.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022
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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