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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001821
Report Date: 09/01/2021
Date Signed: 09/01/2021 11:56:20 AM

Document Has Been Signed on 09/01/2021 11:56 AM - 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:WYCOFF FAMILY CARE HOME IIFACILITY NUMBER:
507001821
ADMINISTRATOR:STACY WYCOFFFACILITY TYPE:
735
ADDRESS:1713 ROBBIE AVENUETELEPHONE:
(209) 548-0249
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 6CENSUS: 5DATE:
09/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Stacy WycoffTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct a Required Annual Inspection. LPA was allowed entry into the facility by care staff and Administrator Stacy Wycoff arrived shortly thereafter.

LPA and Stacy toured and inspected the physical plant inside and outside to ensure all passageways, and other areas of potential hazard are free of obstruction. LPA observed the kitchen and dining area for the ability to prepare food. LPA observed bedrooms and bathrooms, storage areas, laundry and lighting throughout the facility. LPA observed the 2- day perishable and the 7- day non- perishable during this visit.

LPA observed the fire extinguisher(s), carbon monoxide and smoke detectors. Fire extinguishers were observed to be in compliance and were serviced in September 2021. Facility has central heating and air.

Based on today's inspection conducted by LPA Lund, no deficiencies are being cited.

Exit interview held and copy of report given at the conclusion of the visit.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2021
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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