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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490111198
Report Date: 06/15/2021
Date Signed: 06/15/2021 03:15:51 PM

COMPREHENSIVE INSPECTION
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:DOLLY'S MANOR #2FACILITY NUMBER:
490111198
ADMINISTRATOR:MATHEW, DOLLYFACILITY TYPE:
740
ADDRESS:485 JANE DR.TELEPHONE:
(707) 838-3559
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY:6CENSUS: 0DATE:
06/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:07 PM
MET WITH:Licensee, Tom MathewTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct an Annual Required Inspection and met with Licensee Tom Mathew. The inspection is focused on the Infection Control procedures and practices of this facility.

LPA observed that facility has posters up but facility does not currently have any residents in care and does not plan to admit any residents right now.. Licensee will contact CCL before they admit any new residents. Once reopened, LPA will conduct a visit to ensure proper Infection Control protocols are in place.

No deficiencies cited during inspection
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021
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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