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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001821
Report Date: 09/26/2024
Date Signed: 09/26/2024 09:17:45 PM

Document Has Been Signed on 09/26/2024 09:17 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:WYCOFF FAMILY CARE HOME IIFACILITY NUMBER:
507001821
ADMINISTRATOR/
DIRECTOR:		STACY WYCOFFFACILITY TYPE:
735
ADDRESS:1713 ROBBIE AVENUETELEPHONE:
(209) 548-0249
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 6CENSUS: 6DATE:
09/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Administrator Mandy WittharTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct an annual/required inspection. LPA Lund met with Administrator Mandy Witthar and explained the reason for the visit. Census: 6

LPA Lund and Administrator Mandy Witthar toured/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 2023. The medication is centrally stored in the kitchen locked and secured. LPA Lund reviewed two staff & two clients files and are in compliance.


No deficiencies during today’s visit.
Interview held and report left.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024
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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