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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
486803334
Report Date:
04/18/2024
Date Signed:
04/18/2024 10:42:33 AM
Document Has Been Signed on
04/18/2024 10:42 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:
AGING LOVELY
FACILITY NUMBER:
486803334
ADMINISTRATOR/
DIRECTOR:
ALVIS, HIGINIA
FACILITY TYPE:
735
ADDRESS:
1148 HAYES STREET
TELEPHONE:
(707) 421-1665
CITY:
FAIRFIELD
STATE:
CA
ZIP CODE:
94533
CAPACITY:
6
CENSUS:
0
DATE:
04/18/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:
Higinia Alvis
TIME VISIT/
INSPECTION COMPLETED:
10:50 AM
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LPA Hiratsuka conducted this unannounced annual visit.
There are currently no residents in care. Administrator stated she is deciding when she is going to accept new residents. LPA advised Administrator to contact Community Care Licensing Division when she accepts new residents.
A couple of topics were discussed.
No deficiencies cited.
SUPERVISORS NAME
:
Troy Ordonez
LICENSING EVALUATOR NAME
:
Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE
:
DATE:
04/18/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/18/2024
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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