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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804080
Report Date: 11/30/2023
Date Signed: 11/30/2023 10:30:09 AM

Document Has Been Signed on 11/30/2023 10:30 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:DANLE'S CARE HOME IIIFACILITY NUMBER:
486804080
ADMINISTRATOR:DANLE, SINNINFACILITY TYPE:
735
ADDRESS:811 WHITE WING LANETELEPHONE:
(707) 759-2028
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 4CENSUS: 4DATE:
11/30/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:26 AM
MET WITH:Sinin Danle, LicenseeTIME COMPLETED:
10:45 AM
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On 11/30/2023, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of following up on complaint investigation
and conduct a medication count for client (C1) pertaining to complaint investigation. LPA conducted a sample file review for C1 and found all medications properly input on the Centrally Stored Medication and Medication Administration Logs.

In addition, LPA and Licensee discuss current repair status of the facility upstairs restroom and kitchen area. Licensee has been in recent contact with the insurance adjuster but has been delayed for several weeks. LPA was provided with the appropriate contact information to follow up on repairs and determine completion date.

No deficiencies cited.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
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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