<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700755
Report Date: 04/26/2023
Date Signed: 04/26/2023 01:25:11 PM


Document Has Been Signed on 04/26/2023 01:25 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: 0DATE:
04/26/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator Ma Tabitha AntonioTIME COMPLETED:
01:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Jason Lund arrived announced to close the facility. LPA Lund met with Administrator Ma Tabitha Antonio and explained the reason for the visit.

The facility changed locations and three residents moved to the new facility. LPA Lund verified that there are no residents in care at this facility. LPA Lund received the License, and the facility will be closed as of 4/26/2023.

Exit Interview and report left.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1