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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
490111198
Report Date:
06/10/2022
Date Signed:
06/10/2022 09:06:09 AM
COMPREHENSIVE INSPECTION
Document Has Been Signed on
06/10/2022 09:06 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:
DOLLY'S MANOR #2
FACILITY NUMBER:
490111198
ADMINISTRATOR:
MATHEW, DOLLY
FACILITY TYPE:
740
ADDRESS:
485 JANE DR.
TELEPHONE:
(707) 838-3559
CITY:
WINDSOR
STATE:
CA
ZIP CODE:
95492
CAPACITY:
6
CENSUS:
0
DATE:
06/10/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
08:35 AM
MET WITH:
Licensee, Tom Mathew
TIME COMPLETED:
09:10 AM
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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. Licensee will contact CCL if they choose to admit any new residents so LPA can conduct a visit to ensure proper Infection Control protocols are in place.
No deficiencies cited during inspection
SUPERVISOR'S NAME:
Hope DeBenedetti
TELEPHONE:
(707) 588-5059
LICENSING EVALUATOR NAME:
Victoria Willis
TELEPHONE:
(707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE:
06/10/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/10/2022
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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