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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005194
Report Date: 05/18/2023
Date Signed: 05/18/2023 12:39:26 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/18/2023 12:39 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:HERITAGE HOMEFACILITY NUMBER:
507005194
ADMINISTRATOR:ROBERT L. IRWIN, JR.FACILITY TYPE:
740
ADDRESS:943 TERRACE COURTTELEPHONE:
(209) 845-2712
CITY:OAKDALESTATE: CAZIP CODE:
95361
CAPACITY:6CENSUS: 0DATE:
05/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mavis Irwin - Licensee/AdministratorTIME COMPLETED:
12:04 PM
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Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced annual inspection on this date. There are currently no residents in care.

LPA inspected physical plant including but not limited to kitchen, bedrooms, bathrooms, living and dining room area. LPA observed the facility. LPA observed sufficient furniture and lighting throughout the facility.

Fire extinguishers and smoke detectors are current and in compliance with fire safety. Carbon dioxide monitor present.

The facility will be closing a date has not been determined.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, No deficiencies were observed.

Exit interview held and a report given at the conclusion of the visit.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2023
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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