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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
486803788
Report Date:
09/26/2024
Date Signed:
10/15/2024 01:54:00 PM
Document Has Been Signed on
10/15/2024 01:54 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:
BRIGHT MINDS RESIDENTIAL CARE
FACILITY NUMBER:
486803788
ADMINISTRATOR:
DEAN, GRISSEL
FACILITY TYPE:
740
ADDRESS:
2598 BOXWOOD LN
TELEPHONE:
(707) 386-3888
CITY:
FAIRFIELD
STATE:
CA
ZIP CODE:
94533
CAPACITY:
6
CENSUS:
DATE:
09/26/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
10:50 AM
MET WITH:
Kristine Lorenzo, House Manager/Designated Responsible Party
TIME COMPLETED:
11:15 AM
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SUPERVISOR'S NAME:
Bethany Moellers
TELEPHONE:
(707) 588-5040
LICENSING EVALUATOR NAME:
Julie Florio
TELEPHONE:
(707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE:
09/26/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/26/2024
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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