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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800632
Report Date: 01/20/2022
Date Signed: 01/27/2022 02:28:21 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:ANNA HOUSEFACILITY NUMBER:
496800632
ADMINISTRATOR:RIVERA, GUADALUPEFACILITY TYPE:
740
ADDRESS:100 ANNA DRIVETELEPHONE:
(707) 837-8405
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY:6CENSUS: 0DATE:
01/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:TIME COMPLETED:
10:00 AM
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Based on LPA Willis' conversation with Licensee, the facility is closed. Home is currently in escrow and set to close today, 1/20/2022.

LPM DeBenedetti and LPA Willis confirmed by observation that the home is vacant.

Report will be sent to Licensee for signature as they were not available during visit.

LPA will move forward with the closure process.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022
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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