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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801461
Report Date: 01/23/2024
Date Signed: 01/23/2024 03:16:54 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/23/2024 03:16 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:DANA'S FAMILY HOMEFACILITY NUMBER:
486801461
ADMINISTRATOR:THOMAS, DANAFACILITY TYPE:
735
ADDRESS:855 PALERMO DR.TELEPHONE:
(707) 438-7397
CITY:SUISUNSTATE: CAZIP CODE:
94585
CAPACITY: 4CENSUS: 4DATE:
01/23/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Dana Thomas, AdministratorTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived at Dana's Family Home to conduct a case management to continue the Required- 1 Year visit, of 12/07/2023. LPA conducted the visit on 01/23/2024 at approximately 1:45 PM, and met with Administrator Dana Thomas. There are four (4) residents in care. There was one additional staff member present at the time of inspection.

The LPA reviewed four (4) out of four (4) resident files and found them to be complete, with up-to-date quarterly reports. Administrator will request Annual IPPs from regional center. The LPA reviewed two (2) staff files and found them to be complete except to update files to include latest training of staff #1

No citations issued during this inspection.

Exit interview conducted with Administrator.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2024
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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