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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343618745
Report Date: 12/07/2022
Date Signed: 12/07/2022 09:02:23 AM

Document Has Been Signed on 12/07/2022 09:02 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:TUCKER, WILLIAM AND TASHAFACILITY NUMBER:
343618745
ADMINISTRATOR:TUCKER, WM.& TASHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 422-4136
CITY:SACRAMENTOSTATE: CAZIP CODE:
95822
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
12/07/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:William TuckerTIME COMPLETED:
09:15 AM
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Licensing Program Analyst (LPA) Christopher Bello arrived at the facility at approximately 8:30am for an Case Management Licensee Initiated inspection. Today’s inspection regarded changing the status of the license to inactive status. LPA met with licensee William Tucker. No one else was present at time of inspection. LPA printed and provided LIC9211 Inactive Request Form. LPA explained to licensee that when they want to go back to active status to contact the regional office to setup an appointment for an inspection to place them back to active status.

No Title 22 Deficiencies observed in the areas that were evaluated. LPA reviewed report with the director and provided copies. An exist interview was conducted. LPA observed the Notice of Site Visit posted and the director understands it must remain posted for 30 days.
SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Christopher Bello
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2022
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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