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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
507005194
Report Date:
06/11/2024
Date Signed:
06/13/2024 04:37:31 PM
COMPREHENSIVE INSPECTION
Document Has Been Signed on
06/13/2024 04:37 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:
HERITAGE HOME
FACILITY NUMBER:
507005194
ADMINISTRATOR/
DIRECTOR:
ROBERT L. IRWIN, JR.
FACILITY TYPE:
740
ADDRESS:
943 TERRACE COURT
TELEPHONE:
(209) 845-2712
CITY:
OAKDALE
STATE:
CA
ZIP CODE:
95361
CAPACITY:
6
CENSUS:
DATE:
06/11/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:
attempted
TIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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LPA Jensen arrived at facility at approximately 10am. There was no answer at the door. LPA Jensen called and emailed with no response. Moving boxes were visible inside the home. The Department will make another attempt at a later date to complete the required 1 year annual inspection.
SUPERVISORS NAME
:
Lisa Rios
LICENSING EVALUATOR NAME
:
Maja Jensen
LICENSING EVALUATOR SIGNATURE
:
DATE:
06/11/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/11/2024
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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