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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
480102381
Report Date:
04/16/2024
Date Signed:
04/16/2024 10:31:44 AM
Document Has Been Signed on
04/16/2024 10:31 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
SANTA ROSA RO
,
1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA
,
CA
95405
FACILITY NAME:
JO-MIL GROUP HOME
FACILITY NUMBER:
480102381
ADMINISTRATOR/
DIRECTOR:
CHERYL DAVIDSON
FACILITY TYPE:
735
ADDRESS:
143 RUTGERS
TELEPHONE:
(707) 553-1581
CITY:
VALLEJO
STATE:
CA
ZIP CODE:
94589
CAPACITY:
6
CENSUS:
4
DATE:
04/16/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
08:10 AM
MET WITH:
Cheryl Davidson
TIME VISIT/
INSPECTION COMPLETED:
10:35 AM
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LPA Hiratsuka conducted this unannounced annual visit. LPA toured the facility with Caregiver Shane Mills. Administrator Cheryl Davidson arrived during visit. Administrative Assistant Jacqueline Brown-Turner also arrived during visit.
LPA toured all the rooms and common areas. This facility has a fire clearance for six ambulatory residents. There is an office to the left of the main entrance. All residents were at the day program during this visit.
LPA reviewed staff and resident records.
A couple of topics were discussed.
No deficiencies cited.
SUPERVISORS NAME
:
Troy Ordonez
LICENSING EVALUATOR NAME
:
Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE
:
DATE:
04/16/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/16/2024
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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