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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126803764
Report Date: 12/30/2022
Date Signed: 12/30/2022 10:13:14 AM

Document Has Been Signed on 12/30/2022 10:13 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:OUR HOUSEFACILITY NUMBER:
126803764
ADMINISTRATOR:SHANNON, ALEXANDERFACILITY TYPE:
735
ADDRESS:3309 MONTGOMERYTELEPHONE:
(707) 268-0679
CITY:EUREKASTATE: CAZIP CODE:
95503
CAPACITY: 4CENSUS: 4DATE:
12/30/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Sara MeltonTIME COMPLETED:
10:30 AM
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At approximately 9:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a Plan of Correction visit to confirm previous deficiencies were corrected. LPA met with Licensee Sara Melton and toured the facility. LPA inspected client bedrooms and found the damage to the walls and ceiling has been repaired. The clients bathtub has not been repaired. Sara told LPA that the contractor was exposed to Covid and then had a family emergency and was not able to come and repair the tub. LPA reminded Sara to contact LPA if additional time will be needed. Sara stated that due to the earthquake on 12/20/2022, the contractor would need additional time. A civil penalty is being issued for failing to correct the deficiency by the correction due day. The civil penalty is $100 per day, from 12/24/2022 through 12/30/2022, resulting in $700.
Sara will send LPA notification when tub is repaired.


SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2022
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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