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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800368
Report Date: 11/02/2023
Date Signed: 11/02/2023 10:58:33 AM


Document Has Been Signed on 11/02/2023 10:58 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:PARADISE VALLEY ESTATESFACILITY NUMBER:
486800368
ADMINISTRATOR:YEE, KELLYFACILITY TYPE:
741
ADDRESS:2600 ESTATES DRIVETELEPHONE:
(707) 432-1100
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:743CENSUS: 66DATE:
11/02/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:KELLY YEE, ADMINISTRATORTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA), Carol Fowler arrived unannounced for the purpose of conducting a Annual Continuation. LPA was greeted at the door by Administrator, Kelly Yee and was granted access into the facility.

During this Case Management annual Continuation, LPA interviewed 10 staff and 7 residents during this Case Management annual Continuation.

No deficiencies were cited during this Required 1 year inspection. Exit interview was conducted and a copy of this report was signed and given to the Administrator.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023
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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