<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486890081
Report Date: 02/02/2022
Date Signed: 02/04/2022 01:39:20 PM

Document Has Been Signed on 02/04/2022 01:39 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:GOOD SAMARITAN CARE HOME LLCFACILITY NUMBER:
486890081
ADMINISTRATOR:SKILLMAN, TROYFACILITY TYPE:
735
ADDRESS:364 PEPPER DRIVETELEPHONE:
(707) 643-3567
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 0DATE:
02/02/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
04:06 PM
MET WITH:Rosie & Troy SkillmanTIME COMPLETED:
05:27 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Facility Type: Adult Residential Facility
Application Type: Change of Ownership
Capacity: 6
Census (if any clients in care): 4
COMP II Participants: Rosie and Troy Skillman
Interview Method: Telephone interview

On February 2, 2022, applicant/administrator participated in COMP II.
Identification of the applicant/administrator was verified by LPA Canela During COMP II, applicant/administrator confirmed the understanding of the California Code Title 22 Regulations.

During COMP II, LPA confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Reporting requirements
5. General provisions
6. Admissions
7. Pre-licensing readiness
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1