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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490103579
Report Date: 11/13/2023
Date Signed: 11/13/2023 09:29:55 AM


Document Has Been Signed on 11/13/2023 09:29 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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:WOODSIDE WEST SCHOOLFACILITY NUMBER:
490103579
ADMINISTRATOR:DUMBADSE, DIANAFACILITY TYPE:
850
ADDRESS:2577 GUERNEVILLE ROADTELEPHONE:
(707) 528-6666
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY:70CENSUS: 24DATE:
11/13/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Allison FieldsTIME COMPLETED:
09:35 AM
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Licensing Program Analyst (LPA) Amy Strother made a visit to the facility for the purpose of amending the LIC9099-C page, to incorporate additional language, of Complaint Investigation Report dated 11/08/23. LPA met with facility representative, Allison Fields.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2023
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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