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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 176803106
Report Date: 02/09/2023
Date Signed: 02/09/2023 12:48:15 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/09/2023 12:48 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:SAN SOUSEEFACILITY NUMBER:
176803106
ADMINISTRATOR:IMPORTANTE, BE APRILFACILITY TYPE:
735
ADDRESS:14139 KONOCTI STREETTELEPHONE:
(707) 701-6350
CITY:CLEARLAKESTATE: CAZIP CODE:
95422
CAPACITY: 6CENSUS: 0DATE:
02/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Be April Importante, Licensee TIME COMPLETED:
01:00 PM
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On 2/9/2023 at 11:55 AM Licensing Program Analyst (LPA) Shannan Hansen arrived at location and met with Licensee Be April Importante to conduct an annual required visit of this facility.

The licensed facility was destroyed by fire due to the actions of a client on January 26, 2017. At this time no structure exists at this facility location. LPA spoke with licensee to confirm the plan to rebuild the facility. Licensee will notify the Department when construction begins so that LPA can request a new fire clearance and conduct an inspection of the buildings and grounds prior to the repopulation of residents. Licensee provided copies of plans for the rebuild. Licensee is waiting for engineer to authorize and then obtain permits. Licensee agrees to notify the Department should the Licensee decide to change locations or not to reopen. LPA confirmed contact information for Licensee that is changing mailing address and sending in LIC200..

No citations issued at this time
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2023
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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