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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803951
Report Date: 03/25/2022
Date Signed: 03/26/2022 12:35:36 PM


Document Has Been Signed on 03/26/2022 12:35 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:ELEGANCE HAMILTON HILLFACILITY NUMBER:
216803951
ADMINISTRATOR:ACUMABIG, JOSEFACILITY TYPE:
740
ADDRESS:1 HAMILTON HILL DR.TELEPHONE:
(415) 908-1462
CITY:NOVATOSTATE: CAZIP CODE:
94949
CAPACITY:95CENSUS: DATE:
03/25/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Susan Edwards - Executive DirectorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst Fernandes-Goes conducted an unannounced case management and met with new Administrator Susan Edwards. The purpose of the case management visit is due to change of administrator/executive director at this facility.

Department learned on February 16, 2022 that facility had a change of executive director/administrator and that I1 was the new executive director. Department requested documentation and submitted a formal letter on 2/17/22 regarding documentation needed. I1 wasn't associated to facility even though I1 was present, however; I1 was fingerprinted cleared. Corporation staff Chason Archuleta and Lori Okeon were contacted at different occasions as well as I1 regarding association and documentation for change to be effective.
During this visit LPA learned that facility has a new Executive Director/Administrator Susan Edwards who started around 3/09/2022 and is fingerprint cleared and associated to the facility. Department is requesting the following documentation for change of administrator.

LIC 200 Application (must be original)
LIC 308 Designation of Facility responsibility (designation of who is the administrator)
Administrator Certificate
Administrator Resume
LIC 500 Personnel Report
LIC 610 Emergency Disaster Plan for Residential Care Facilities for the Elderly
LIC 501 Personnel Record
Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations)
Copy Diploma Certificate

There were no deficiencies cited at this time.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022
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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