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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
342700469
Report Date:
10/26/2023
Date Signed:
10/26/2023 03:09:37 PM
Document Has Been Signed on
10/26/2023 03:09 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 NORTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
GREAT HAVEN
FACILITY NUMBER:
342700469
ADMINISTRATOR:
EZE, CHINYERE
FACILITY TYPE:
740
ADDRESS:
71 GROTH CIR
TELEPHONE:
(916) 833-6388
CITY:
SACRAMENTO
STATE:
CA
ZIP CODE:
95834
CAPACITY:
6
CENSUS:
DATE:
10/26/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:15 AM
MET WITH:
TIME COMPLETED:
09:30 AM
NARRATIVE
1
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5
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9
10
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19
20
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23
24
25
Made an attempt to conduct a 1 year required visit. No one was home.
SUPERVISORS NAME
:
Laura Munoz
LICENSING EVALUATOR NAME
:
DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE
:
DATE:
10/26/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/26/2023
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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