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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803967
Report Date: 01/14/2025
Date Signed: 01/14/2025 11:07:21 AM

Document Has Been Signed on 01/14/2025 11:07 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:LONGSPUR MANORFACILITY NUMBER:
486803967
ADMINISTRATOR/
DIRECTOR:		ANGELES, JANNEFACILITY TYPE:
735
ADDRESS:1107 LONGSPUR DRTELEPHONE:
(415) 939-4491
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 4CENSUS: 4DATE:
01/14/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Janne Angeles, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:05 AM
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On 01/14/2025, Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced for the purpose of following up on a self reported incident regarding resident (C1). LPA discussed with Administrator Janne Angeles. Cleint C1 reported to staff they had been sexually assaulted by a date which took place at a nearby park. This date was supervised by staff S1. C1 and staff (S1, S2, S3) were interviewed. According to staff interviews, C1 was within line of sight at all times at the time of encounter and no sexual assault took place. LPA gathered client documents for review and discussed the incident with Administrator and Licensee.

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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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