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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801208
Report Date: 04/26/2023
Date Signed: 04/26/2023 10:43:22 AM


Document Has Been Signed on 04/26/2023 10:43 AM - 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:HILL HOUSE, THEFACILITY NUMBER:
496801208
ADMINISTRATOR:HILL, RALPHFACILITY TYPE:
740
ADDRESS:8840 EGG FARM LANETELEPHONE:
(707) 833-1157
CITY:KENWOODSTATE: CAZIP CODE:
95452
CAPACITY:6CENSUS: 4DATE:
04/26/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Prospective Licensee, Rosa SotoTIME COMPLETED:
10:45 AM
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An office meeting was conducted today in the Santa Rosa Regional Office with Licensing Program Manager (LPM), Bethany Moellers, Licensing Program Analyst (LPA), Farhaan Sarangi and Prospective Licensee, Rosa Soto, Prospective Administrator, Ivan Soto and Caregiver, Fortino Soto regarding the Emergency Approval to Operate (EAO) for Hill House, The #496801208. Licensee passed away and Prospective Licensee, Rosa Soto will continue the operation of this facility.

Prospective Licensee has provided the following documents with the intent to continue operation of the facility:

- Application fee.
- Death certificate for licensee
- LIC200.
- LIC500.
- Control of property – Trust Documents.
- Administrator Certificate.
- Orientation Certificate
- Fire Clearance Sketch (LIC999)
- Infection Control Plan.

During today's meeting we received the application fee along with the above documents. RO will inquire with CAB regarding the obtained Trust and appointing the LLC to Rosa Soto after death of Licensee. Rosa Soto will have 60 days to send the remaining documents for the application. A copy of the documents submitted was provided to Rosa Soto.

No deficiencies cited during today's office meeting

SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023
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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