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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801028
Report Date: 10/13/2021
Date Signed: 10/13/2021 02:11:52 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:DRAKE TERRACEFACILITY NUMBER:
216801028
ADMINISTRATOR:RICARDO ROMEROFACILITY TYPE:
740
ADDRESS:275 LOS RANCHITOS ROADTELEPHONE:
(415) 491-1935
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:130CENSUS: 111DATE:
10/13/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, Ricardo RomeroTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Drake Terrace for the purposes of conducting an Unannounced Case Management-Incident inspection. LPA met with Administrator, Ricardo Romero, and was granted access into the facility.

During the Case Management-Incident inspection, LPA observed resident and interviewed resident and Administrator. In addition, LPA requested the following documents be emailed to LPA's attention by October 15, 2021. Below is a list of documents to be sent to CCL:

-LIC 500
-Staff disciplinary termination form
-Statement from R1
-LIC 602

No deficiencies were observed or cited during today's Case Management-Incident inspection. Exit interview was conducted and a copy of this report will be emailed to the Administrator, Ricardo Romero.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
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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