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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236804031
Report Date: 03/22/2022
Date Signed: 03/22/2022 02:55:34 PM

Document Has Been Signed on 03/22/2022 02:55 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:PHOENIX HOUSEFACILITY NUMBER:
236804031
ADMINISTRATOR:ADDISON, DENISEFACILITY TYPE:
772
ADDRESS:641 S ORCHARD AVETELEPHONE:
(707) 467-2010
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY: 8CENSUS: 0DATE:
03/22/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Kristin BognerTIME COMPLETED:
03:10 PM
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At 1:00PM, Licensing Program Analyst (LPA) Chris Arnhold met with Applicants to conduct a pre-Licensing inspection. Applicants were Victoria Kelly, Kristin Bogner and Administrator Denise Addison.

LPA inspected facility building and grounds and observed no hazards. Facility has appropriate fire alarms and carbon monoxide monitors in place. Water temperature at sinks accessible to clients was within regulation. Toxins and cleaners are locked and inaccessible. Kitchen, bedrooms, bathrooms, and halls were clean and contained required furniture and supplies. There is plenty of food and emergency supplies. There is a locked space for medication and records. Client files along with other facility records are kept on a computer database. There are activity rooms, quite rooms, and offices available if needed.


The pre-licensing evaluation has been completed. LPA will submit the application packet for a final review and approval from the Licensing Program Manager.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2022
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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