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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801563
Report Date: 03/18/2022
Date Signed: 03/18/2022 11:21:32 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/18/2022 11:21 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:BECOMING INDEPENDENT-SANTA ROSAFACILITY NUMBER:
496801563
ADMINISTRATOR:COX, JAMESFACILITY TYPE:
775
ADDRESS:1455 CORPORATE CENTER PKWY.TELEPHONE:
(707) 524-6600
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 285CENSUS: 0DATE:
03/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:James Cox (Executive Director)TIME COMPLETED:
09:20 AM
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Licensing Program Analyst (LPA) Cuadra arrived to conduct an Annual Required inspection and met with Day Program Executive Director, James Cox. Facility is not currently open and is not providing day program services. This site is under construction and not operational. LPA discussed with Executive Director about their mailing address because there are mail being returned to the Department and he agreed to submit a LIC200 to change mailing address to a deliverable address.

No deficiencies cited during today's inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2022
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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