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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
507004929
Report Date:
10/17/2023
Date Signed:
10/25/2023 03:12:33 PM
Document Has Been Signed on
10/25/2023 03:12 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 SOUTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
DUTCHOLLOW SUITES I
FACILITY NUMBER:
507004929
ADMINISTRATOR:
CANDIDO, CECILIA
FACILITY TYPE:
740
ADDRESS:
4112 LAURANT COURT
TELEPHONE:
(209) 521-0566
CITY:
MODESTO
STATE:
CA
ZIP CODE:
95356
CAPACITY:
6
CENSUS:
3
DATE:
10/17/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
01:00 PM
MET WITH:
Cecelia Candido
TIME COMPLETED:
04:15 PM
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On 10/17/23 at approximately 1pm Licensing Program Analyst arrived at facility unannounced to conduct a required 1 year annual visit. LPA Jensen met with Licensee Cecelia Candido and explained the purpose of today's visit.
Due to time constraints this annual inspection will require additional time to complete at a later date. No deficiencies are being issued at this time.
SUPERVISORS NAME
:
Stephenie Doub
LICENSING EVALUATOR NAME
:
Maja Jensen
LICENSING EVALUATOR SIGNATURE
:
DATE:
10/17/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/17/2023
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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