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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804246
Report Date: 01/03/2025
Date Signed: 01/03/2025 04:40:50 PM

Document Has Been Signed on 01/03/2025 04:40 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:4 SEASONSFACILITY NUMBER:
486804246
ADMINISTRATOR/
DIRECTOR:		MATHURIN, HERBYFACILITY TYPE:
735
ADDRESS:907 HARLEQUIN WAYTELEPHONE:
(415) 629-1205
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 5CENSUS: 2DATE:
01/03/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:20 PM
MET WITH:Herby Mathurin, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
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At approximately 3:20 PM Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a Case Management - Incident visit. LPA was greeted by Herby Mathurin, Licensee/Administrator. LPA informed Licensee the purpose of today's visit was to investigate a suicide threat by Client 1 (C1) as reported via incident report (IR) dated 12/05/2024. LPA requested copies of C1's most recent medication list, and notes from all of C1's hospital visit, IPP, ISP, and any psychiatry visit notes.

During visit LPA made observations, went over incident details, gathered records, and conducted an interview with Licensee. Per review of records obtained and interview, staff addressed the incident as needed, when it occurred.

Facility made all appropriate notifications per regulation.

No Deficiencies cited during visit.

Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Administrator/Licensee. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2025
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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