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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493008040
Report Date: 12/03/2019
Date Signed: 12/03/2019 11:22:23 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:BLACK, HEATHER FCCHFACILITY NUMBER:
493008040
ADMINISTRATOR:BLACK, HEATHERFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 225-8753
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY:14CENSUS: 11DATE:
12/03/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Heather BlackTIME COMPLETED:
12:05 PM
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
Licensing Program Analyst (LPA), Leticia Rosales-Meza conducted an unannounced case management visit in follow up to the recent Public Safety Power Shutoffs (PSPS) and fire evacuations. Licensee confirmed there was no significant impact, power was not shutoff, facility was closed for two days. The facility is observed to be in full operation today with no identified health and safety issues or unmet needs. LPA also verified the most current contact information. No deficiencies cited for areas observed today.

Notice of Site Visit shall be posted for 30 days from today's visit
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Leticia RosalesTELEPHONE: (707) 588-5061
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2019
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