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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
486804016
Report Date:
01/14/2024
Date Signed:
01/14/2024 10:45:46 AM
Document Has Been Signed on
01/14/2024 10:45 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
SANTA ROSA RO
,
1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA
,
CA
95405
FACILITY NAME:
HER ONLY DAUGHTER SENIOR CARE HOME
FACILITY NUMBER:
486804016
ADMINISTRATOR:
BOOKER, JANAI
FACILITY TYPE:
740
ADDRESS:
130 PURDUE DR.
TELEPHONE:
(707) 295-3200
CITY:
VALLEJO
STATE:
CA
ZIP CODE:
94589
CAPACITY:
5
CENSUS:
0
DATE:
01/14/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:00 AM
MET WITH:
Janai Booker
TIME COMPLETED:
10:55 AM
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LPA Hiratsuka conducted this announced visit for the annual visit. LPA attempted the annual yesterday and called the licensee and was informed this location does not have any residents at this time.
LPA toured this facility with Licensee Janai Booker. No health and safety concerns were observed.
Multiple topics were discussed.
LPA requested Licensee to inform Community Care Licensing when she admits her first resident.
No deficiencies cited.
SUPERVISOR'S NAME:
Troy Ordonez
TELEPHONE:
(916) 263-4832
LICENSING EVALUATOR NAME:
Kerry Hiratsuka
TELEPHONE:
(916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE:
01/14/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/14/2024
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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