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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803577
Report Date: 05/11/2023
Date Signed: 05/12/2023 08:13:35 AM

Document Has Been Signed on 05/12/2023 08:13 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:WALDO HOUSEFACILITY NUMBER:
216803577
ADMINISTRATOR:LOTT, SHERIFACILITY TYPE:
735
ADDRESS:55 WALDO COURTTELEPHONE:
(415) 271-3304
CITY:SAUSALITOSTATE: CAZIP CODE:
94965
CAPACITY: 5CENSUS: 0DATE:
05/11/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator, Sherri LottTIME COMPLETED:
03:16 PM
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LPA Bertozzi and LPM Moellers met virtually with Administrator, Sherri Lott and Program Director Paula Sufflett as well as representatives of Golden Gate Regional Center: Collin Ellsworth, Sulma Chavez, Trina Falabrino-Silva, Kristal Baxter and Skylar Spencer.

Parties met to discuss facility elopement protocols and the placement status of client, C1 in addition to plans to keep client and staff safe until other placement can be found.

Facility agrees to submit an updated elopement plan for C1 to include, but not limited to, possible 1:1 supervision, shadowing client via foot when eloping and utilizing a 24-hour crisis unit to respond to elopement no later than May 25, 2023.

No deficiencies cited during this visit.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2023
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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