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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001821
Report Date: 08/19/2022
Date Signed: 08/19/2022 02:50:49 PM

Document Has Been Signed on 08/19/2022 02:50 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: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:
08/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:house manager Mandy Witthar TIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Jason Lund arrived at the above address unannounced to conduct a annual/required inspection. LPA was allowed entry into the facility by house manager Mandy Witthar who called Administrator/Licensee Stacy Wycoff. Administrator/Licensee Stacy Wycoff could not the visit and gave approval for house manager Mandy Witthar to sign required paperwork

LPA and house manager Mandy Witthar 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 October 2021. Facility has central heating and air.

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

Exit interview held with Administrator/Licensee Stacy Wycoff over the phone and house manager Mandy Witthar and copy of report given at the conclusion of the visit.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2022
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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