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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803786
Report Date: 09/22/2022
Date Signed: 09/22/2022 08:25:22 PM


Document Has Been Signed on 09/22/2022 08:25 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:ISLES ASSISTED LIVING FACILITY, THEFACILITY NUMBER:
486803786
ADMINISTRATOR:EFE, ELENAFACILITY TYPE:
740
ADDRESS:129 PACER DRTELEPHONE:
(707) 254-5444
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 5DATE:
09/22/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:07 AM
MET WITH:Suzette TawzerTIME COMPLETED:
11:53 AM
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Licensing Program Analyst (LPA), Araceli Canela arrived unannounced regarding another matter. The purpose of this Case Management visit is to address the facility unpaid annual fees. Administrator explained, they did not receive notification but will be paying the annual fees within 5 days and send proof to LPA Canela.

LPA advised, failure to bring her facility fees current may result in the facility being cited.

No citations issued during this visit.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022
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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