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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
496800494
Report Date:
05/05/2023
Date Signed:
05/05/2023 03:41:30 PM
COMPREHENSIVE INSPECTION
Document Has Been Signed on
05/05/2023 03:41 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:
MIRNA HOUSE
FACILITY NUMBER:
496800494
ADMINISTRATOR:
MATHEW, THOMAS
FACILITY TYPE:
740
ADDRESS:
106 MIRNA COURT
TELEPHONE:
(707) 953-4371
CITY:
WINDSOR
STATE:
CA
ZIP CODE:
95492
CAPACITY:
6
CENSUS:
0
DATE:
05/05/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
03:28 PM
MET WITH:
Licensee Tom Mathew
TIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required Inspection and met with Licensee Tom Mathew.
LPA conducted a walk through of the facility and confirmed that there are currently no residents in care. Facility does not have a current plan to admit residents but may in the future. Licensee will contact CCL if they choose to admit any new residents so LPA can conduct a visit prior to move-in.
No deficiencies cited during inspection
SUPERVISOR'S NAME:
Hope DeBenedetti
TELEPHONE:
(707) 588-5059
LICENSING EVALUATOR NAME:
Victoria Bertozzi
TELEPHONE:
(707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE:
05/05/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/05/2023
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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