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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 564700080
Report Date: 09/04/2024
Date Signed: 09/04/2024 09:47:36 PM

Document Has Been Signed on 09/04/2024 09:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
HOME CARE SERVICES, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
FACILITY NAME:FAMILY TIES HOME CARE LLCFACILITY NUMBER:
564700080
ADMINISTRATOR/
DIRECTOR:		CATHY BELSKYFACILITY TYPE:
300
ADDRESS:1350 LAFITTE DR.TELEPHONE:
(805) 917-6680
CITY:OAK PARKSTATE: CAZIP CODE:
91377
CAPACITY: CENSUS: DATE:
09/04/2024
Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Adam BelskyTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Enforcement Analyst (EA), Joshua Rarela, with the Home Care Services Branch (HCSB) conducted an onsite inspection for the purpose of obtaining signatures and delivering an amended report. The EA met with the Home Care Organization (HCO) representative named above.

An exit interview was conducted. A copy of this report and amended reports were provided to the HCO representative named above.
LICENSING EVALUATOR NAME: Joshua Rarela
LICENSING EVALUATOR SIGNATURE: DATE: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

HCS809 (FAS) - (06/04)
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