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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
486802010
Report Date:
01/25/2024
Date Signed:
01/25/2024 09:55:40 AM
Document Has Been Signed on
01/25/2024 09:55 AM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO
,
1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA
,
CA
95405
FACILITY NAME:
GOOD SAMARITAN CARE HOME
FACILITY NUMBER:
486802010
ADMINISTRATOR:
GARCIA, BRENDA
FACILITY TYPE:
740
ADDRESS:
3113 PEBBLE BEACH CIRCLE
TELEPHONE:
(707) 718-0498
CITY:
FAIRFIELD
STATE:
CA
ZIP CODE:
94534
CAPACITY:
6
CENSUS:
DATE:
01/25/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
08:30 AM
MET WITH:
Facility Staff- Joti Zulita
TIME COMPLETED:
10:00 AM
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LPA arrived to conduct an annual which was not due for this facility.
LPA conducted a full annual, no deficiencies noted.
Arrived at this facility in error.
SUPERVISOR'S NAME:
Lauren Crocker
TELEPHONE:
(916) 261-4966
LICENSING EVALUATOR NAME:
Jaynae Boyles
TELEPHONE:
(916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE:
01/25/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/25/2024
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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