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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
345003020
Report Date:
05/09/2024
Date Signed:
05/09/2024 04:23:57 PM
Document Has Been Signed on
05/09/2024 04:23 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:
CARMICHAEL ESTATES NO. 1
FACILITY NUMBER:
345003020
ADMINISTRATOR/
DIRECTOR:
DELUCA, DAVID
FACILITY TYPE:
740
ADDRESS:
5228 EL CAMINO AVE
TELEPHONE:
(406) 533-8372
CITY:
CARMICHAEL
STATE:
CA
ZIP CODE:
95608
CAPACITY:
6
CENSUS:
3
DATE:
05/09/2024
TYPE OF VISIT:
Post Licensing
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
04:45 PM
MET WITH:
David Deluca
TIME VISIT/
INSPECTION COMPLETED:
05:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a required annual inspection. LPA met with Administartor and explained the purpose of the visit.
LPA is conducting an annual inspection today but this report is being generated to clear the Post-Licensing inspection in the system.
There are no citations issued on this report.
Exit interview. Copy of report provided.
SUPERVISORS NAME
:
Anthony Perez
LICENSING EVALUATOR NAME
:
Cassie Yang
LICENSING EVALUATOR SIGNATURE
:
DATE:
05/09/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/09/2024
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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