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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800827
Report Date: 04/11/2023
Date Signed: 10/09/2023 10:08:08 AM

Document Has Been Signed on 10/09/2023 10:08 AM - 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:TINA'S GENTLE CARE HOMES IIFACILITY NUMBER:
425800827
ADMINISTRATOR:VALENTINA ROBERTSFACILITY TYPE:
740
ADDRESS:1411 W. SABRINA COURTTELEPHONE:
(805) 925-0748
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY: 6CENSUS: 4DATE:
04/11/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
05:10 PM
MET WITH:Michael Joseph Elizarde, Administrator and Valentina Roberts, LicenseeTIME COMPLETED:
05:20 PM
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Due to a technical error, Licensing Program Analyst (LPA) continued the 4/11/2023 annual visit using the CARE tool on this report. Please reference the Required 1-Year visit report from 4/11/2023 for more information.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2023
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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