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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800912
Report Date: 10/17/2023
Date Signed: 10/17/2023 10:21:54 AM

Document Has Been Signed on 10/17/2023 10:21 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BEACONLIGHT CARE HOMEFACILITY NUMBER:
216800912
ADMINISTRATOR:HYPPOLITE, WALLYFACILITY TYPE:
735
ADDRESS:1468 SOUTH NOVATO BLVDTELEPHONE:
(415) 756-5525
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 6CENSUS: 6DATE:
10/17/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Administrator, Wally HyppoliteTIME COMPLETED:
10:30 AM
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Licensing Program Analysts (LPAs) Rummonds and Felias arrived unannounced to conduct a Case Management - Other Visit to follow up on deficiencies cited on 08/29/2023. LPAs met with Administrator, Wally Hyppolite. LPAs toured the facility at approximately 9:45 to check on the following areas: client bedrooms, backyard, ceiling, and closet noted in annual report dated 08/29/2023.

LPAs observed the areas cleaned up from previous visit. LPAs discussed with Administrator moving some gardening and outdoor equipment to a shed.

No deficiencies cited during visit.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023
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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