<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002859
Report Date: 10/04/2023
Date Signed: 10/04/2023 01:19:24 PM

Document Has Been Signed on 10/04/2023 01:19 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:MOAIFACILITY NUMBER:
345002859
ADMINISTRATOR:FOWLER, CRAIG M.FACILITY TYPE:
740
ADDRESS:2633 CARDINAL COURTTELEPHONE:
(916) 844-5250
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 3CENSUS: 0DATE:
10/04/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Craig FowlerTIME COMPLETED:
01:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/4/2023, Licensing Program Analysts (LPAs) Cassie Yang and Cheyenne Ratajczak arrived to the facility unannounced to conduct a case management visit to complete the inspection tool from annual inspection conducted on 09/27/2023. LPAs met with Licensee, Craig Fowler, and explained the purpose of the visit.

LPAs completed the CARE tool which was not finalized during last visit.

During today's visit, no deficiencies cited.

Exit interview, and a copy of the report was provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1