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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803869
Report Date: 06/20/2024
Date Signed: 06/20/2024 02:22:23 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/20/2024 02:22 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:HYDEE'S CARE HOME LLCFACILITY NUMBER:
486803869
ADMINISTRATOR/
DIRECTOR:		RAMIREZ, HYDEEFACILITY TYPE:
735
ADDRESS:1175 JACK LONDON DRIVETELEPHONE:
(707) 704-8353
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 3DATE:
06/20/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Jane Ramirez, Assistant AdminstratorrTIME VISIT/
INSPECTION COMPLETED:
02:25 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to complete the 1-Year Annual Inspection on 6/20/2024. There were 2 carestaff, 1 maintenance director and 1 client at the facility at the time of inspection. 2 clients were attending their Day Program at the time.

LPA returned to review the facility records and personnel files. LPA had a discussion on 6/14/2024 with Licensee/Administrator after the Annual Visit on 6/13/2024 discussing the requirement that the Department is to have access to facility files at all times. Licensee/Administrator agreed to address the issue. On 06/20/2024 LPA was granted access to the facility and found the files immediately available for inspection. LPA was able to complete annual inspection and reviewed 5 personnel files and found them to be complete.

No deficiencies were found at the time of inspection and no citations issued.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
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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