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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800881
Report Date: 04/05/2022
Date Signed: 04/14/2022 09:50:02 AM

Document Has Been Signed on 04/14/2022 09:50 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:SAN LUIS HOUSEFACILITY NUMBER:
216800881
ADMINISTRATOR:TOOTLE, MICHELLEFACILITY TYPE:
735
ADDRESS:396 SAN LUIS WAYTELEPHONE:
(415) 897-5716
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY: 6CENSUS: 0DATE:
04/05/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Michelle Tootle - AdministratorTIME COMPLETED:
02:00 PM
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Licensing Program Manager (LPM) Bethany Moellers, Licensing Program Analyst (LPA) Carla Fernandes-Goes met with Licensee Representative Administrators Jim Rosetti and facility administrator Michelle Tootle virtually.

This Informal Conference is being conducted to discuss concerns identified by the Licensing Agency in regards to the operation of this facility including but not limited to address multiple unexplained injuries to clients in care. Reference complaints # 21-AS-20210414135710 April, 2021; # 21-AS-20211020160657 October, 2021; and # 21-AS-20211229150035 12/2021.

Facility has implement new procedures and policies to address staff training for observation of clients in care.

No deficiencies cited at today's informal conference.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2022
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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