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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803873
Report Date: 07/02/2024
Date Signed: 07/02/2024 03:46:55 PM


Document Has Been Signed on 07/02/2024 03:46 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 PATH CARE HOMEFACILITY NUMBER:
486803873
ADMINISTRATOR:DEAN, GRISSELFACILITY TYPE:
740
ADDRESS:2170 HAUSAM LANETELEPHONE:
(707) 386-3888
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: 6DATE:
07/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Kristine Lorenzo, House ManagerTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a Case Management - Inspection. The purpose of this case management visit was to follow up on a self reported incident report that was submitted to Community Care Licensing (CCL) on 6/17/2024 regarding client C1.

During visit LPA went over incident details, gathered records, took statement from House Manager, and made observations. Per review of today's records and interviews, staff addressed the incident as needed, when it occurred.

No deficiencies were found at the time of visit. No citations issued.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie FlorioTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024
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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