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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
486803810
Report Date:
08/11/2023
Date Signed:
08/11/2023 10:01:42 AM
Document Has Been Signed on
08/11/2023 10:01 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
CCLD Regional Office
,
1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA
,
CA
95405
FACILITY NAME:
COGIR OF NORTH BAY
FACILITY NUMBER:
486803810
ADMINISTRATOR:
DOMIZIO, ANNEMARIE
FACILITY TYPE:
740
ADDRESS:
2261 TUOLUMNE ST
TELEPHONE:
(707) 552-3336
CITY:
VALLEJO
STATE:
CA
ZIP CODE:
94589
CAPACITY:
83
CENSUS:
75
DATE:
08/11/2023
TYPE OF VISIT:
POC
UNANNOUNCED
TIME BEGAN:
09:30 AM
MET WITH:
Tracy freudendahl
TIME COMPLETED:
10:00 AM
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Licensing Program Analyst Leibert returns today for POC visit. LPA meet with the Administrator and takes test ride in the elevator. Repairs have been made subsequent to the last visit and the control button for the third floor is now fully functional. Deficiency is cleared.
Report left.
No citations issued today.
SUPERVISOR'S NAME:
Carla Martinez
TELEPHONE:
(707) 588-5059
LICENSING EVALUATOR NAME:
David Leibert
TELEPHONE:
(707) 588-5086
LICENSING EVALUATOR SIGNATURE:
DATE:
08/11/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/11/2023
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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