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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803662
Report Date: 11/01/2021
Date Signed: 11/08/2021 01:47:26 PM

Document Has Been Signed on 11/08/2021 01:47 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:PEACH HUB, THEFACILITY NUMBER:
486803662
ADMINISTRATOR:GARCIA, JIM BERNARD PFACILITY TYPE:
775
ADDRESS:380 PITTMAN ROADTELEPHONE:
(707) 389-2403
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 45CENSUS: DATE:
11/01/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jim Garcia, AdministratorTIME COMPLETED:
01:45 PM
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LPA Lopez and LPM Moellers conducted an informal meeting via phone due to Zoom technical difficulties about a self reported incident submitted to Community Care Licensing 9/9/21 with Administrator, Jim Garcia. LPA and LPM were following up on an unlawful eviction notice that was given to C1. Administrator explained situation to LPA and LPM. LPM asked follow up questions and suggested on how to proceed with this incident. Administrator agreed to reach out to regional center about this incident to find ways to resolve and also to communicate with all staff if there is an issue so they are all aware.

No deficiencies cited during this office visit.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Karen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2021
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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