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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803869
Report Date: 08/10/2023
Date Signed: 08/10/2023 04:22:31 PM

Document Has Been Signed on 08/10/2023 04:22 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:HYDEE'S CARE HOME LLCFACILITY NUMBER:
486803869
ADMINISTRATOR:RAMIREZ, HYDEEFACILITY TYPE:
735
ADDRESS:1175 JACK LONDON DRIVETELEPHONE:
(707) 704-8353
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 3DATE:
08/10/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Ernesto Ramirez, CaregiverTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA), Carol Fowler arrived unannounced for the purpose of conducting a Annual Continuation. LPA was greeted at the door by Caregiver, Ernesto Ramirez, and was granted access into the facility.

During this Case Management annual Continuation, LPA reviewed resident files during this Case Management annual Continuation.

No deficiencies were cited during this Required 1 year inspection. Exit interview was conducted and a copy of this report was signed and given to the Caregiver.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2023
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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