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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801989
Report Date: 10/14/2021
Date Signed: 10/15/2021 11:21:23 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:BENICIA ANGEL'S HOME 2 INC.FACILITY NUMBER:
486801989
ADMINISTRATOR:BAYON, EVELYNFACILITY TYPE:
740
ADDRESS:116 CARLISLE WAYTELEPHONE:
(707) 748-0482
CITY:BENICIASTATE: CAZIP CODE:
94510
CAPACITY:6CENSUS: 0DATE:
10/14/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:46 AM
MET WITH:Evelyn BayonTIME COMPLETED:
10:47 AM
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Licensing Program Analyst (LPA) A. Canela arrived unannounced at Benicia Angel's Home 2 Inc on 10/14/2021 for the purpose of conducting a final walk-through of Licensee Initiated Facility Closure. LPA called licensee by phone and Evelyn Bayon arrived a few minutes later.

The licensee surrender the license to the Department and LPA received the license in the office on Monday October 11, 2021. LPA conducted walk through with Licensee, of the first, second level of the home and outside to confirm no residents are present. Facility has had no residents in care since, February 2021 and facility was observed empty with no bedroom furniture or resident items. Licensee notified LPA the facility was in the market and recently sold.



LPA will close facility as of today.
No citations issued.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
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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