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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 280100627
Report Date: 09/22/2022
Date Signed: 09/22/2022 02:46:25 PM


Document Has Been Signed on 09/22/2022 02:46 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:PINER'S GUEST HOMEFACILITY NUMBER:
280100627
ADMINISTRATOR:PINER, GARYFACILITY TYPE:
740
ADDRESS:1800 PUEBLO AVENUETELEPHONE:
(707) 255-3461
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:28CENSUS: 10DATE:
09/22/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Supervisor of Assisted Living, Kathy Hulbert TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 09/22/2022 to conduct a case management inspection regarding an incident report received by Community Care Licensing on 08/26/2022. LPA met with Supervisor of Assisted Living, Kathy Hulbert.

During the inspection LPA conducted interview and obtained documents.

Exit interview conducted with Kathy Hulbert and a copy of this report printed for the facility.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022
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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