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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490109162
Report Date: 03/30/2022
Date Signed: 03/30/2022 01:30:37 PM


Document Has Been Signed on 03/30/2022 01:30 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:OLD ADOBE SCHOOLFACILITY NUMBER:
490109162
ADMINISTRATOR:MURRAY, MICHAELAFACILITY TYPE:
850
ADDRESS:252 WEST SPAIN STREETTELEPHONE:
(707) 408-2383
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY:45CENSUS: 34DATE:
03/30/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Michaela Murray, DirectorTIME COMPLETED:
01:45 PM
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LPA Kevin O'Connell made an inspection visit for the purpose of obtaining signatures and delivering an amended 9099D page correcting CR 101229 (Responsibility for Providing Care & Supervision) to HSC 1596.99(c)(3) (Levy of civil penalty in addition to suspension, temporary suspension, or revocation, amounts; regulations setting forth appeal procedures for deficiencies).

Notice of Site Visit is to be posted for 30 days from today.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Kevin O'ConnellTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
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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