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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804106
Report Date: 03/20/2025
Date Signed: 03/20/2025 04:31:29 PM

Document Has Been Signed on 03/20/2025 04:31 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:INCLUSION SPECIALIZED PROGRAMS - DAWN WAYFACILITY NUMBER:
486804106
ADMINISTRATOR/
DIRECTOR:		AMBRIZ, PATRICIAFACILITY TYPE:
735
ADDRESS:2449 DAWN WAYTELEPHONE:
(562) 305-7599
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
03/20/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Patti Ambriz, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Julie Florio conducted a case management- incident inspection, on 3/20/25 at approximately 3:00pm, and met with Patti Ambriz, Administrator.

LPA is conducting a case management visit to obtain more information regarding an incident, dated 03/14/2025, involving Client 1 (C1), which was reported by Administrator. LPA reviewed C1's records and obtained copies of documents including a personnel roster/report. Facility made the appropriate notifications and has implemented preventative measures for C1 moving forward.

No deficiencies were cited during todays visit.

Exit interview was conducted with Administrator, whose signature on form confirms receipt of document.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
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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