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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
486804044
Report Date:
02/02/2024
Date Signed:
02/02/2024 12:46:50 PM
Document Has Been Signed on
02/02/2024 12:46 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
CCLD Regional Office
,
1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA
,
CA
95405
FACILITY NAME:
KREATIVE COMMUNITY SERVICES - BLOOM
FACILITY NUMBER:
486804044
ADMINISTRATOR:
ALOE, SHAYNE
FACILITY TYPE:
775
ADDRESS:
1241 ALAMO DRIVE SUITE 7
TELEPHONE:
(707) 474-9653
CITY:
VACAVILLE
STATE:
CA
ZIP CODE:
95687
CAPACITY:
60
CENSUS:
12
DATE:
02/02/2024
TYPE OF VISIT:
Case Management - Annual Continuation
UNANNOUNCED
TIME BEGAN:
12:29 PM
MET WITH:
Danielle Guisande, Program Manager
TIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Jill Nakagawa continued the Annual Inspection in order to complete the Care Tool.
No deficiencies were found during the course of the inspection or in the completion of the care tool.
No citations issued.
SUPERVISORS NAME
:
Kimberley Mota
LICENSING EVALUATOR NAME
:
Jill Nakagawa
LICENSING EVALUATOR SIGNATURE
:
DATE:
02/02/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/02/2024
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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