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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801923
Report Date: 06/21/2024
Date Signed: 06/24/2024 09:59:52 AM


Document Has Been Signed on 06/24/2024 09:59 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:YOUNG AT HEART RCFEFACILITY NUMBER:
216801923
ADMINISTRATOR:ROMUALDOFORTEZ,BELLANACHORFACILITY TYPE:
740
ADDRESS:37 MENDOCINO LANETELEPHONE:
(415) 209-6185
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY:6CENSUS: 0DATE:
06/21/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:TIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced to conduct a Case Management inspection to confirm that all residents have moved out of the facility.

Upon arrival, LPA observed a for sale sign on the street. LPA knocked on the door and there was no answer. LPA observed the house to be empty.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Helena RummondsTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2024
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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