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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480102469
Report Date: 04/18/2024
Date Signed: 04/18/2024 09:01:06 AM

Document Has Been Signed on 04/18/2024 09:01 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:CLARK-RO HOMEFACILITY NUMBER:
480102469
ADMINISTRATOR/
DIRECTOR:
SKILLMAN, C.W. & R.LFACILITY TYPE:
735
ADDRESS:242 CORTLANDTELEPHONE:
(707) 642-9361
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 5CENSUS: 2DATE:
04/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:50 AM
MET WITH:Tracy SkillmanTIME VISIT/
INSPECTION COMPLETED:
09:05 AM
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LPA Hiratsuka conducted this unannounced annual visit.

This facility has a fire clearance for five ambulatory residents. There are three resident rooms. There is one resident room that has a full private bathroom and one full common bathroom. There is one staff room. All common areas and resident rooms were inspected. No issues were observed.

Several other topics were discussed.

The following shall be updated and submitted to Community Care Licensing Division by May 3, 2024:
-LIC 308 designation of administrative responsibility
-liability insurance
-LIC 500 facility personnel or staff schedule
-plan for Incidental Medical and Dental Care
-copy of surety bond


no deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
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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