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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700785
Report Date: 11/08/2021
Date Signed: 11/08/2021 04:45:41 PM

Document Has Been Signed on 11/08/2021 04:45 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:7125 MAIN, LLCFACILITY NUMBER:
342700785
ADMINISTRATOR:GLADYS GASTAFACILITY TYPE:
740
ADDRESS:7125 MAIN AVETELEPHONE:
(707) 592-4004
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 6CENSUS: 0DATE:
11/08/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Margaret Agengo, CaregiverTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the care home today to conduct a Required-1 Year Inspection and Post Licensing visit. Prior to visit, LPA contacted Administrator, Robert Coleman, via telephone, who permitted caregiver to sign report.

For more information on the Post Licensing visit, please see LIC 809 for Required-1 Year Inspection dated 11/8/21.

No deficiencies cited for the post licensing visit.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2021
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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