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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126803772
Report Date: 10/10/2023
Date Signed: 10/10/2023 08:11:57 AM

Document Has Been Signed on 10/10/2023 08:11 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:WINDSONGFACILITY NUMBER:
126803772
ADMINISTRATOR:KIM JOHNSONFACILITY TYPE:
735
ADDRESS:500 SILER LANE UNIT BTELEPHONE:
(707) 798-6319
CITY:EUREKASTATE: CAZIP CODE:
95501
CAPACITY: 25CENSUS: DATE:
10/10/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Brian AlmondTIME COMPLETED:
08:30 AM
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At approximately 8:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit in regards to an error made in a report for a visit made on 10/09/2023. LPA met with manager on duty, Brian Almond. LPA incorrectly wrote the times of the visit and document review. This visit was made to amend that report.

No citations issued during this visit.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2023
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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