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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126803838
Report Date: 03/11/2024
Date Signed: 03/11/2024 01:59:22 PM


Document Has Been Signed on 03/11/2024 01:59 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:ROSELAND CARE HOMEFACILITY NUMBER:
126803838
ADMINISTRATOR:SMITH, CLEOFACILITY TYPE:
740
ADDRESS:6449 PURDUE DRTELEPHONE:
(707) 442-7330
CITY:EUREKASTATE: CAZIP CODE:
95503
CAPACITY:6CENSUS: DATE:
03/11/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Cleo Smith, AdministratorTIME COMPLETED:
01:58 PM
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An office meeting was conducted today in the Santa Rosa Regional Office with Licensing Program Manager (LPM), Bethany Moellers, Licensing Program Analyst (LPA), Jill Nakagawa and Cleo Smith, current Licensee/Administrator. The purpose of today’s meeting is to discuss and issue Emergency Approval to Operate (EAO) for Roseland Care Home, #126803838. Current license is issued as a partnership, CCL was informed of the passing of one of the Licensee’s. Cleo Smith will continue the operation of this facility.
Cleo Smith, Licensee has provided the following documents with the intent to continue operation of the facility:
Section A and B of the Application packet and application fee, pending a few documents to make application packet complete.

Smith will have 60 days to send the remaining documents for the application to the Application Unit (CAB).

No deficiencies cited during today's office meeting.

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2024
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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