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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800621
Report Date: 12/16/2022
Date Signed: 12/16/2022 01:46:38 PM

Document Has Been Signed on 12/16/2022 01:46 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: DATE:
12/16/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Pia Baroni (Licensee)TIME COMPLETED:
01:40 PM
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An office meeting was conducted today in the Santa Rosa Regional Office via Microsoft Teams due to the licensee who is appointed Administrator is out of town for an extended amount of time 10/1/2022 to Present). Present in the meeting were Licensing Program Manager Bethany Moellers, Licensing Program Analyst Marisol Cuadra, NBRC Kirk Jarret and Licensee Pia Baroni.

The purpose of the informal office meeting was to discuss concerns identified by the Licensing Agency regarding to the operation of this facility including but not limited to: Complaint investigation #21-AS-20221019125728 that has been substantiated for Facility failed to ensure the building was clean, safe, sanitary and in good repair at all times. Other concerns that have been observed during visits are the operation of Wimbledon House 1 #496800621.

Items addressed in today's meeting include but are not limited to patterns and trends in the areas below:

· Staffing concerns
· Maintenance and Operation.
· Acting Administrator and involvement in facility operation

Documents requested during informal meeting to be submitted to CCL by 12/21/2022:
· Updated Personnel Report (LIC 500)
· Plan to ensure that facility will be kept clean, sanitary and in good repair at all times.
· Licensee/Administrator is present in the facility to ensure adequate oversight of the facility.

Regulation 85064 and 80065 were provide to Licensee. Failure to submit above documentation may result in the Department seeking further action.

No deficiencies cited during today's office meeting

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2022
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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