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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
486800629
Report Date:
06/07/2022
Date Signed:
06/07/2022 03:07:23 PM
Document Has Been Signed on
06/07/2022 03:07 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
,
1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA
,
CA
95405
FACILITY NAME:
WOODRIDGE HOME
FACILITY NUMBER:
486800629
ADMINISTRATOR:
ELAINE GO
FACILITY TYPE:
735
ADDRESS:
184 WOODRIDGE CIRCLE
TELEPHONE:
(707) 447-5572
CITY:
VACAVILLE
STATE:
CA
ZIP CODE:
95687
CAPACITY:
6
CENSUS:
3
DATE:
06/07/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
01:45 PM
MET WITH:
Staff, Emilia Berinda
TIME COMPLETED:
03:12 PM
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Licensing Program Analyst (LPA) Walters arrived at this facility unannounced to follow up on items previously requested from the facility. LPA was greeted by staff. The Administrator was not present for today's visit.
On 4/29/22 LPA requested that the facility sends pictures as proof that the facility has stocked the refrigerator as required per regulation. LPA conducted a visit on today's date to ensure facility was meeting requirements. LPA toured the facility and observed that the facility had a food supply for residents as required by regulation.
No items cited during today's visit.
SUPERVISORS NAME
:
Hope DeBenedetti
LICENSING EVALUATOR NAME
:
Katrina Walters
LICENSING EVALUATOR SIGNATURE
:
DATE:
06/07/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/07/2022
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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