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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803852
Report Date: 04/18/2024
Date Signed: 04/18/2024 01:33:39 PM

Document Has Been Signed on 04/18/2024 01:33 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:THRIVE ADULT RESIDENTIAL CARE II, INC.FACILITY NUMBER:
486803852
ADMINISTRATOR/
DIRECTOR:		MARIA GOLITZENFACILITY TYPE:
735
ADDRESS:2340 CABOT CTTELEPHONE:
(510) 689-4911
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
04/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:37 PM
MET WITH:Direct Support Staff Samuel Baena and David SalamidaTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
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LPA Hiratsuka conducted this unannounced annual visit.

This facility has a fire clearance for ambulatory residents. There are four private resident rooms. One resident room has a full private bathroom. There is one full common bathroom. Common areas, resident rooms, and office were toured and no hazards observed. There is a locked cabinet for medications. The perishable and nonperishable food supply meets regulations. The backyard was inspected. There is a locked shed in the backyard.

Four resident files and three staff files were reviewed.

The following shall be updated and submitted to Community Care Licensing Division by May 3, 2024:
-LIC 308 designation of administrative responsibility
-liability insurance
-LIC 500 facility personnel or staff schedule
-Articles of Incorporation or Organization, Constitutional and Bylaws

The annual fees are due by April 16th of every year. As of April 12, 2024, the annual fees were not yet paid.
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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