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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803926
Report Date: 02/09/2024
Date Signed: 02/09/2024 12:36:45 PM


Document Has Been Signed on 02/09/2024 12:36 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:EVAS CARE HOMEFACILITY NUMBER:
486803926
ADMINISTRATOR:MULDER, EVAFACILITY TYPE:
740
ADDRESS:319 ATLANTIC AVETELEPHONE:
(510) 890-8777
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: DATE:
02/09/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Eva Mulder, AdministratorTIME COMPLETED:
12:45 PM
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Licensing Program Manager Victoria Bertozzi and Licensing Program Analyst Christi Coppo conducted an informal office meeting, and met with Administrator Eva Mulder.

This informal meeting is being conducted to discuss concerns identified in regards to the operation of this facility, including but not limited to the admission process, appraisals, medications, and administrator qualifications and duties.

Licensing staff and Administrator discussed a recent situation regarding a resident who was not provided their medication. During Case Management inspection dated 1/30/2024, LPA Coppo was unable to obtain required resident records and other documents from the Licensee/Administrator. Per conversation today, Administrator is unsure of regulation requirements regarding the admission process, eviction process and other areas of Title 22 regulations.

Licensee has not yet decided if they plan to continue licensure at this time but will update CCL. Licensee also expressed interest in the Department's Technical Support Program. LPM will obtain further information regarding the program. Licensee must review Title 22 regulation and their Plan of Operation to ensure compliance. Continued non-compliance may result in a Non-Compliance Plan.

Licensing provided the following forms to the Licensee to update:
Admission Agreement

No deficiencies cited during today’s informal non-compliance office visit.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024
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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