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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216802050
Report Date: 07/06/2023
Date Signed: 07/06/2023 12:33:38 PM


Document Has Been Signed on 07/06/2023 12:33 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:LUCAS VALLEY LODGEFACILITY NUMBER:
216802050
ADMINISTRATOR:ANGLADE, GREGOIREFACILITY TYPE:
740
ADDRESS:70 MOUNT TENAYA DRIVETELEPHONE:
(415) 377-4888
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:4CENSUS: 0DATE:
07/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Administrator, Gregoire AngladeTIME COMPLETED:
12:40 PM
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At approximately 12:10PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Other visit and met with Administrator, Gregoire Anglade. The purpose of the visit is to conduct a walk through and confirm closure of the facility.

LPA and Administrator conducted a walk through of the facility. LPA inspected the rooms and the exterior of the building today and found no evidence that would suggest that any clients are residing on the premises. All clothing and personal items belonging to clients have been removed. All items left in facility are the personal belongings of the Administrator.

The Licensee initiated this facility closure. On 06/13/2023, LPA Felias was notified by Licensee/Administrator, Gregoire Anglade about their plan to close the facility. As of today's visit, the facility closure has been finalized and is effective, today, 07/06/23. Licensee provided LPA with their original copy of their license. Licensee understands that if they wish to reopen their facility, a new application will have to be submitted and processed by the Department of Social Services.

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: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2023
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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