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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
507001131
Report Date:
12/15/2021
Date Signed:
12/15/2021 02:40:22 PM
Document Has Been Signed on
12/15/2021 02:40 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:
DAVIS GUEST HOME IV
FACILITY NUMBER:
507001131
ADMINISTRATOR:
JESSICA SANCHEZ
FACILITY TYPE:
735
ADDRESS:
1552 OHIO AVENUE
TELEPHONE:
(209) 549-0772
CITY:
MODESTO
STATE:
CA
ZIP CODE:
95358
CAPACITY:
34
CENSUS:
30
DATE:
12/15/2021
TYPE OF VISIT:
POC
UNANNOUNCED
TIME BEGAN:
10:15 AM
MET WITH:
Jessica Sanchez
TIME COMPLETED:
11:45 AM
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LPA Johnson met with the Administrator to conduct POC Inspection from 809 and 809-D dated 10/24/2021.
POC's corrected.
Deficiencies cleared.
POC letter printed.
Exit interview.
SUPERVISORS NAME
:
Stephenie Doub
LICENSING EVALUATOR NAME
:
Albert Johnson
LICENSING EVALUATOR SIGNATURE
:
DATE:
12/15/2021
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/15/2021
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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