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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480102469
Report Date: 10/28/2021
Date Signed: 10/28/2021 02:49:44 PM

Document Has Been Signed on 10/28/2021 02:49 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:CLARK-RO HOMEFACILITY NUMBER:
480102469
ADMINISTRATOR:SKILLMAN, C.W. & R.LFACILITY TYPE:
735
ADDRESS:242 CORTLANDTELEPHONE:
(707) 642-9361
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 5CENSUS: 4DATE:
10/28/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Rosie Skillman, LicenseeTIME COMPLETED:
02:50 PM
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On 10/28/2021 LPA Tobola conducted an unannounced Case Management Inspection Visit for the purpose of a health and safety check to review several items observed during inspection by North Bay Regional Center.

LPA was greeted by Licensee, Rosie Skillman and conducted a tour of the facility. There are currently 4 clients in care all of which were present. Facility was found to be in good condition. LPA inspected items listed by NBRC and found all items to be in compliance in areas observed.

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2021
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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