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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801569
Report Date: 05/27/2021
Date Signed: 05/27/2021 10:38:41 AM

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:DOVER TERRACE RESIDENTIAL CARE HOMEFACILITY NUMBER:
486801569
ADMINISTRATOR:GADIA, EDWARDFACILITY TYPE:
740
ADDRESS:1043 SPARROW LANETELEPHONE:
(707) 421-2575
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: 0DATE:
05/27/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ed Gadia, Administrator and LicenseeTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Karina Canela met with Ed Gadia, Administrator and Licensee, on 05/27/2021 to complete a final walk-through for Licensee initiated facility closure. LPA toured the facility with Licensee to confirm there are no residents present.

Licensee stated they have not had residents since March 2021, they were relocated to another licensed facility. Licensee provided letter for closure previously and LPA obtained facility license. LPA did not observe any Community Care Licensing (CCL) required postings for Dover Terrace Residential Care Facility. LPA will send out a forfeiture letter to Licensee and complete closure process.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
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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