FACILITY EVALUATION REPORT REFER TO

STATE OF california HEALTH AND HUMAN services AGENCYCALIFORNIA department OF social SERVICESFACILITY EVALUATION REPORTREFER TOSee other side for explanation of NAMELICENSING EVALUATOR SIGNATURETELEPHONE( )DATEFACILITY REPRESENTATIVE SIGNATUREDATEI understand my licensing appeal rights asexplained on the back of this ( )NAME OF SUPERVISORADDRESSCOMMENTS/DEFICIENCIESPL AN OF CORRECTIONS (POCs)POCDUE DATETYPE OF VISIT: OFFICE MANAGEMENT PRELICENSING ANNUAL FOLLOW-UPDEFICIENCY INFORMATION FOR THIS PAGE: Type A No Deficiency Cited Type BCIVIL PENALTY INFORMATION: Penalty Assessed Penalty Notice Given Penalty Cleared Not Applicable MET WITH ANNOUNCED UNANNOUNCEDTELEPHONE()CAPACITYCENSUSDATE TIME VISIT BEGANTIME COMPLETEDDIRECTORFACILITY NUMBERFACILITY TYPEF ailure to correct the above cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in acivil penalty 809 (12/15)AGENCY COPYPage _____ of _____ pagesFACILITY EVALUATION REPORT california law requires a public REPORT of each licensing visit.

STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES FACILITY EVALUATION REPORT REFER TO …

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