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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801993
Report Date: 10/14/2022
Date Signed: 10/14/2022 02:51:07 PM

Document Has Been Signed on 10/14/2022 02:51 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:CICADA-MILL VALLEYFACILITY NUMBER:
216801993
ADMINISTRATOR:NOEL CAMATOGFACILITY TYPE:
735
ADDRESS:309 ENTERPRISE CONCOURSETELEPHONE:
(415) 888-3880
CITY:MILL VALLEYSTATE: CAZIP CODE:
94941
CAPACITY: 6CENSUS: 6DATE:
10/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Daniel Limpin, House ManagerTIME COMPLETED:
03:00 PM
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On 10/14/2022 LPA Tobola conducted an unannounced case management visit for the purpose of retrieving fire clearance documentation from the facility. LPA Tobola was greeted by House Manager, Daniel Limpin and contacted Administrator, Noel Camatog by phone to discuss documentation for the fire clearance. LPA was informed that the Fire Inspector had conducted a visit on 10/11/2022 but facility is waiting for documentation/report to be provided.

LPA will be in contact with Fire Marshall and Administrator for CCLD documentation.

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2022
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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