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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801572
Report Date: 04/25/2023
Date Signed: 04/25/2023 04:33:58 PM

Document Has Been Signed on 04/25/2023 04:33 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:OUR HOUSEFACILITY NUMBER:
486801572
ADMINISTRATOR:OKEIGWE, HELENFACILITY TYPE:
735
ADDRESS:2201 TUOLUMNE STREETTELEPHONE:
(707) 558-1777
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 46CENSUS: 43DATE:
04/25/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Helen Okeigwe, DirectorTIME COMPLETED:
04:45 PM
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On 4/25/2023, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of following up on a self reported incident and death report for resident (R1) who was reported to have been found deceased after leaving the facility on 4/20/2023. LPA gathered client documents for review and discussed the incident with Program Director and Administrator.

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2023
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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