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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801117
Report Date: 04/28/2022
Date Signed: 04/28/2022 12:39:25 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 04/28/2022 12:39 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:BIRDIE HOUSEFACILITY NUMBER:
496801117
ADMINISTRATOR:CHRISTINE WOLTERINGFACILITY TYPE:
740
ADDRESS:1402 BIRDIE DRIVETELEPHONE:
(707) 837-9010
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY: 6CENSUS: 0DATE:
04/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:07 AM
MET WITH:Christine Woltering (Licensee)TIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Licensee, Christine Woltering. Facility is currently under remodel process including painting, changing flooring and upgrades doesn't include any major changes, two residents were relocated to sisters facility Amber House (496800153) and Ashley House (496801118). This facility is currently not providing care services. CCL was not informed that this facility was under remodel and residents relocation. LPA discussed with Licensee that it is a CCL requirement to report any changes to the facility in a timely manner. Licensee agreed to submit pertinent documentation to CCL by not later than April 29, 2022 and will notify CCL prior to moving residents back to the facility.

No deficiencies cited during today's inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
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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