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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480102381
Report Date: 08/20/2021
Date Signed: 08/20/2021 10:30:53 AM

Document Has Been Signed on 08/20/2021 10:30 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:JO-MIL GROUP HOMEFACILITY NUMBER:
480102381
ADMINISTRATOR:CHERYL DAVIDSONFACILITY TYPE:
735
ADDRESS:143 RUTGERSTELEPHONE:
(707) 553-1581
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 5DATE:
08/20/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Cheryl Davidson, AdministratorTIME COMPLETED:
10:40 AM
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On 8/20/2021 LPA Tobola conducted a case management visit and was greeted by Administrator, Cheryl Davidson. LPA toured the facility and made observations. LPA gathered documents and conducted interviews with staff.

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2021
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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