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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803956
Report Date: 05/05/2023
Date Signed: 05/05/2023 09:57:23 AM

Document Has Been Signed on 05/05/2023 09:57 AM - 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:CONNECTED LIVING VACAVILLEFACILITY NUMBER:
486803956
ADMINISTRATOR:TRAIL, SARAFACILITY TYPE:
735
ADDRESS:82 MANZANITA DRIVETELEPHONE:
(925) 826-6830
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 5CENSUS: 3DATE:
05/05/2023
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Cederick Tanner, Lead StaffTIME COMPLETED:
10:15 AM
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On 5/5/2023 Licensing Program Analyst (LPA) Tobola arrived announced to conduct a scheduled case management visit regarding the facility increase in overall capacity and was greeted by Lead Staff Cederick Tanner. The facility was previously licensed to provide care for 3 ambulatory clients. A fire clearance has been granted by the Vacaville Fire Department on 4/27/2023 for the facility to provide care to 5 ambulatory clients. Upon inspection LPA found the facility shared master bedroom will be utilized for two potential incoming clients referred by North Bay Regional Center.

At this time the facility is in the process of review for an increase in services from level 3 to level 4i. North Bay Regional Center has been notified of the request and informed CCLD that the Department of Developmental Services must complete their review before updated vendor is granted. The facility is currently vendorized by North Bay Regional Center for a total of 3 clients. The Licensee agrees to comply with the current vendor capacity and provide updates to CCLD on increase services determination.

No citations issued.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2023
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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