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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
216803239
Report Date:
05/04/2022
Date Signed:
05/09/2022 11:42:23 AM
Document Has Been Signed on
05/09/2022 11:42 AM
- It Cannot Be Edited
Document is an Amendment of
Original Document
on
05/06/2022 03:29 PM
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
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*****amended report.
LIC809 generated in error under this facility.
SUPERVISOR'S NAME:
Bethany Moellers
TELEPHONE:
(707) 588-5026
LICENSING EVALUATOR NAME:
Shannan Hansen
TELEPHONE:
707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE:
05/09/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/09/2022
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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