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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102878
Report Date: 01/12/2021
Date Signed: 01/13/2021 01:37:24 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:NAZARETH HOUSE OF SAN RAFAEL, INC.FACILITY NUMBER:
210102878
ADMINISTRATOR:GOLZE, RYAN S.FACILITY TYPE:
740
ADDRESS:245 NOVA ALBION WAYTELEPHONE:
(415) 479-8282
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:146CENSUS: 0DATE:
01/12/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ryan Golze - Executive DirectorTIME COMPLETED:
11:50 AM
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Licensing Program Analysts (LPAs) Fernandes-Goes & Farhaan Sarangi conduct an unannounced tele-visit inspection, on 1/12/2021 at approximately 11:00 AM in regards to Facility Closure initiated by the licensee. The inspection is being conducted by tele-inspection due to COVID-19. The reader is advised that the LPAs did not physically make a site visit. At the time of inspection there were 0 residents. LPAs have learned that all 66 residents have been relocated - see LIC 812 for resident's names and facility.

LPAs toured the facility with Executive Director Ryan Golze; toured grounds, including dinning area, common areas, sample of bedrooms, and kitchen in order to determine if there exist any signs of residents remaining at the facility. All clothing and personal items belonging to residents have been moved out, and LPAs found no evidence that residents remain in care at the facility.

Executive Director will mail the surrendered original license to Community Care Licensing (CCL) to affect the closure on 1/12/2021. The licensee also provided documentation regarding the closure on 9/2020.


The facility is now officially closed.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2021
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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