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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 086804160
Report Date: 02/10/2025
Date Signed: 02/10/2025 01:52:58 PM

Document Has Been Signed on 02/10/2025 01:52 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:GLEN HAVEN DAY PROGRAMFACILITY NUMBER:
086804160
ADMINISTRATOR/
DIRECTOR:		HALL, JACOBFACILITY TYPE:
775
ADDRESS:680 E. WASHINGTON BLVDTELEPHONE:
(707) 954-3113
CITY:CRESCENT CITYSTATE: CAZIP CODE:
95531
CAPACITY: 30CENSUS: 10DATE:
02/10/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Jacob HallTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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At approximately 1:30PM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit. LPA met with Licensee Jacob Hall.
Licensee expressed that since the Covid pandemic is over, they no longer wish to take part in the emergency shelter program.

No citations issued during today's visit.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2025
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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