<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490110022
Report Date: 06/23/2022
Date Signed: 06/23/2022 11:16:22 AM


Document Has Been Signed on 06/23/2022 11:16 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:A SPECIAL PLACEFACILITY NUMBER:
490110022
ADMINISTRATOR:WENDY ADAMSFACILITY TYPE:
850
ADDRESS:1128 EDWARDS AVENUETELEPHONE:
(707) 523-2337
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY:30CENSUS: 12DATE:
06/23/2022
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Laura VoightTIME COMPLETED:
11:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LPA Strother arrived at the facility for the purpose of conducting interviews. The interviews conducted were concerning a matter related to a complaint investigation unrelated to this facility, A Special Place.

There were no Title 22 deficiencies cited during today's inspection.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with facility representative, Laura Voight.

SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1