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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210111734
Report Date: 05/28/2024
Date Signed: 05/28/2024 11:38:40 AM


Document Has Been Signed on 05/28/2024 11:38 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:WILD FLOWERS RCFEFACILITY NUMBER:
210111734
ADMINISTRATOR:ALLEN, C. ELIZABETHFACILITY TYPE:
740
ADDRESS:256 SUNSET PARKWAYTELEPHONE:
(415) 264-7399
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY:6CENSUS: 3DATE:
05/28/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Elizabeth AllenTIME COMPLETED:
12:00 PM
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Licensing Program Analyst Leibert arrived unannounced for the purpose of reviewing the circumstances of the death of a resident of the facility. The resident, R1, died on 04/20/2024. LPA toured the facility, reviewed documents, and spoke with staff. R1 was not on Hospice and was quite elderly with multiple medical problems. LPA verified that the required notification were made by the facility and that no unusual circumstances were found.

Report left.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:
DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2024
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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