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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490111198
Report Date: 01/08/2024
Date Signed: 01/08/2024 03:19:15 PM


Document Has Been Signed on 01/08/2024 03:19 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: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:
01/08/2024
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Licensee/Administrator Tom MathewTIME COMPLETED:
03:30 PM
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At approximately 3:00PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Other visit and met with Licensee/Administrator, Tom Mathew. The purpose of the visit is to conduct a walk through and confirm closure of the facility.

LPA and Administrator conducted a walk through of the facility. LPA inspected the rooms and the exterior of the building today and found no evidence that would suggest that any clients are residing on the premises. All clothing and personal items belonging to clients have been removed. All items left in facility are the personal belongings of the Administrator.

The Licensee initiated this facility closure. On 12/13/2023, LPA was notified by Licensee/Administrator, Tom Mathew about their plan to close the facility and provided the Regional Office with their original license. A of today, 01/08/2024, the facility closure has been finalized and is effective. Licensee understands that if they wish to reopen their facility, a new application will have to be submitted and processed by the Department of Social Services.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2024
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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