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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801686
Report Date: 11/01/2022
Date Signed: 11/01/2022 06:02:42 PM


Document Has Been Signed on 11/01/2022 06:02 PM - 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:ALDERSLYFACILITY NUMBER:
216801686
ADMINISTRATOR:GILBERT CARRASCOFACILITY TYPE:
741
ADDRESS:326 MISSION AVENUETELEPHONE:
(415) 453-7425
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY:137CENSUS: DATE:
11/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Administrator, Momo DuoaTIME COMPLETED:
04:30 PM
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At approximately 3:45PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Other visit, and met with Administrator, Momo Duoa.

The purpose of the visit is to discuss the facility's dementia care program. Documents supporting the program will be submitted to Community Care Licensing (CCL).

No deficiencies cited during visit.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2022
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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