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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126803772
Report Date: 11/29/2023
Date Signed: 11/30/2023 08:31:19 AM

Document Has Been Signed on 11/30/2023 08:31 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:
11/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Kim JohnsonTIME COMPLETED:
09:15 AM
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At approximately 9:00AM, Licensing Program Analyst (LPA) contacted Administrator Kim Johnson to correct the report generated on 10/09/2023.
LPA conducted the Required 1 year inspection on 10/09/2023. The report was amended on the same day, resulting in the system not registering the visit as completed. This report is to correct the system.

Original signature on file.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2023
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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