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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236804031
Report Date: 03/29/2022
Date Signed: 03/29/2022 11:26:17 AM

Document Has Been Signed on 03/29/2022 11:26 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
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:
03/29/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Denise AddisonTIME COMPLETED:
11:40 AM
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At approximately 10:35AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility announced, to conduct the Component III orientation with Administrator. LPA met with Administrator Denise Addison and conducted the orientation.

The Pre-Licensing visit was conducted on 03/22/2022.

This application will be submitted to the Licensing Program Manager for review.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2022
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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