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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 504700023
Report Date: 11/10/2021
Date Signed: 11/12/2021 08:43:18 AM

Document Has Been Signed on 11/12/2021 08:43 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
FACILITY NAME:HHCV GROUP LLCFACILITY NUMBER:
504700023
ADMINISTRATOR:BECKER, TIMOTHEFACILITY TYPE:
300
ADDRESS:117 KETCH LANETELEPHONE:
(209) 409-8585
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 0CENSUS: DATE:
11/10/2021
Case Management - Biennial Required ContinuationUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:TIME COMPLETED:
09:30 AM
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On 11/10/2021, an attempt was made to perform an unannounced inspection of HHCV Group LLC. A licensee or designee shall be continuously present during the Home Care Organization’s (HCO) business office hours. Any additional incomplete inspections may result in the issuance of civil penalties or possible license revocation. Please notify your assigned analyst of any changes to the HCO location or anticipated hours of operation. The hours of operation and license should be displayed on the premises as well.
LICENSING EVALUATOR NAME: Ruben Perez
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

HCS809 (FAS) - (06/04)
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