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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800494
Report Date: 02/14/2024
Date Signed: 02/14/2024 03:11:34 PM


Document Has Been Signed on 02/14/2024 03:11 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:MIRNA HOUSEFACILITY NUMBER:
496800494
ADMINISTRATOR:MATHEW, THOMASFACILITY TYPE:
740
ADDRESS:106 MIRNA COURTTELEPHONE:
(707) 953-4371
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY:6CENSUS: 0DATE:
02/14/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Thomas Mathew-LicenseeTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Alviso arrived to conduct an annual visit, on 2/14/24 at approximately 2:30pm, and met with Thomas Mathew, Licensee.

LPA toured the facility and observed no clients in care. The Licensee stated that they want to surrender the license, as they no longer want to operate the care facility.

Licensee provided a letter requesting the facility license be closed. Licensee Thomas Mathew provided the Department license to the LPA during the inspection.

If wanting to operate a care home at this address in the future, an application would need to be filed with the Department, and go through the application process.

The license is no longer valid. The facility license is closed today, effective 2/14/2024..
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024
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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