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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803243
Report Date: 04/15/2024
Date Signed: 04/15/2024 04:03:44 PM

Document Has Been Signed on 04/15/2024 04:03 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:CAREBESTFACILITY NUMBER:
486803243
ADMINISTRATOR/
DIRECTOR:		ZHANG, GUOLIANFACILITY TYPE:
735
ADDRESS:2376 BURGUNDY WAYTELEPHONE:
(707) 427-8776
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 3DATE:
04/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:40 PM
MET WITH:Guolian ZhangTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Hiratsuka conducted this unannounced annual visit. Licensee/Administrator Guolian "Mark " Zhang, arrived during visit.

There are currently three residents. There is one shared resident room and two private resident rooms. There is one staff room. There are two full common bathrooms and one full private bathroom. There is an ample supply of perishable and non-perishable food. LPA reviewed two staff and two client files.

Today LPA discussed the following with Licensee:
Licensee called Community Care Licensing Division (CCLD) on 03/14/2024, stating he opened a corporation to operate the facility. The LPA Licensee spoke to gave Licensee incomplete information. Today, LPA Hiratsuka clarified what the other LPA was explaining. LPA Hiratsuka informed Licensee in order to have the corporation operate the facility Licensee is required to submit a brand new application under the corporation's name. LPA Hiratsuka told Licensee effective immediately all operations shall revert back to the original Licensee and not under the corporation. If Licensee wishes to have the corporation own and operate the facility at a later date a brand new, complete application shall be submitted to CCLD.
-LPA Hiratsuka is going to contact the CCLD Santa Rosa office to clarify the fire clearance. The facility is operating correctly. LPA noticed a discrepancy.

The following shall be updated and submitted to CCLD by April 30, 2024:
-LIC 308 Designation of Administrative Responsibility
-liability insurance
-LIC 500 facility personnel or staff schedule


No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2024
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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