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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804135
Report Date: 04/25/2023
Date Signed: 04/25/2023 03:31:12 PM

Document Has Been Signed on 04/25/2023 03:31 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:JOSHUA'S HAVENFACILITY NUMBER:
286804135
ADMINISTRATOR:TAMBOT-SUNGA, DEYRAFACILITY TYPE:
735
ADDRESS:236 NEWBURY WAYTELEPHONE:
(650) 892-4572
CITY:AMERICAN CANYONSTATE: CAZIP CODE:
94503
CAPACITY: 4CENSUS: 0DATE:
04/25/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Deyra Tambot-SungaTIME COMPLETED:
03:45 PM
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At approximately 1:00PM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility for the purpose of completing a pre-licensing evaluation. LPA met with Applicant Deyra Tambot-Sunga and toured the facility. The Facility is a 4-bedroom, 2-bathroom, single story house. Fire extinguisher was mounted and charged. Smoke detectors were tested and in working order. Carbon monoxide detector was present. There was a locked area for medications and several for toxins and cleaning supplies. Beds were made with appropriate linens. Resident rooms contained furniture as required in 4 of 4 rooms. Hot water temperature was tested and found to be within regulation between 105 degrees F and 120 degrees F at faucets accessible to residents.

A fire clearance for this facility has been granted.

Component III orientation was conducted at facility. Applicant conveyed a good knowledge of Title 22 regulations.

The pre-licensing evaluation has been completed. LPA will submit the application packet for a final review and approval from the Licensing Program Manager.

This report was reviewed with applicant and a copy was provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2023
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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