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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801426
Report Date: 10/03/2023
Date Signed: 10/03/2023 12:53:56 PM

Document Has Been Signed on 10/03/2023 12:53 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:THRUSHWING HOMEFACILITY NUMBER:
496801426
ADMINISTRATOR:KRYSTAL AMBRECHTFACILITY TYPE:
735
ADDRESS:128 THRUSHWING AVENUETELEPHONE:
(707) 843-4880
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY: 4CENSUS: 2DATE:
10/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Administrator, Krystal AmbrechtTIME COMPLETED:
01:03 PM
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Licensing Program Analysts Bertozzi and Coppo arrived unannounced to conduct a Case Management inspection and met with Administrator, Krystal Ambrecht.

LPAs are following up regarding a self-reported death of a client. LPAs conducted a file review and spoke with Administrator. Per conversation with Administrator, an autopsy will be completed and a death certificate issued following the autopsy. Once completed, facility will obtain a copy of the certificate and provide to CCL.

No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2023
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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