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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800621
Report Date: 11/01/2022
Date Signed: 11/01/2022 12:43:00 PM

Document Has Been Signed on 11/01/2022 12:43 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:WIMBLEDON HOUSE #1FACILITY NUMBER:
496800621
ADMINISTRATOR:BARONI, PIA E.FACILITY TYPE:
735
ADDRESS:629 WEST 3RD STREETTELEPHONE:
(707) 527-7628
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 5CENSUS: 2DATE:
11/01/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Elizabeth Ramirez (Staff)TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA), Cuadra arrived unannounced for the purpose of conducting a Case Management-Other-Health & Safety (H&S) Inspection. LPA met with Staff, Elizabeth Ramirez.

LPA/staff toured the facility and found that the facility is at a temperature of 69 degrees with exits free from obstruction. LPA observed sufficient perishable and non-perishable foods. LPA checked water temperatures in one out of one faucet and found that the temperature of the water was at 114.1 degrees. During the Case Management-Other-Health & Safety (H&S) inspection, LPA learned that the facility hired additional staff to provide coverage for Elizabeth. LPA reviewed facility records and staff (S1) was associated to the facility as of 10/29/22. Licensee agreed to submit LIC308 form to CCL for review because staff was not able to locate the form on file.

No deficiencies cited during today's inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2022
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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