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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803951
Report Date: 05/04/2022
Date Signed: 05/04/2022 01:46:17 PM


Document Has Been Signed on 05/04/2022 01:46 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: 31DATE:
05/04/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Susan Edwards - Executive DirectorTIME COMPLETED:
01:45 PM
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Licensing Program Analyst Fernandes-Goes conducted an unannounced case management and met with Executive Director Susan Edwards. The purpose of the case management visit is to amend annual required visit report conducted on 4/19/2022.

In addition, facility to submit documentation that was requested on 4/19/22 due on 4/27/2022. Facility to submit documentation ASAP to CCLD. Facility New Executive Director - 2 months still has documentation change as requested prior. (see below)

LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 610E-S Supplemental Emergency Disaster Plan for RCFE
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Certificate of Liability Insurance
Copy of Administrator Certificate

Change of Administrator
LIC 200 Application (must be original)
LIC 308 Designation of Facility responsibility (designation of who is the administrator)
Administrator Certificate
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: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022
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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