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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
496801598
Report Date:
04/25/2023
Date Signed:
04/25/2023 12:16:11 PM
Document Has Been Signed on
04/25/2023 12:16 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:
NORTH BAY REHABILITATION SERVICES
FACILITY NUMBER:
496801598
ADMINISTRATOR:
VANDERGRIEND, LANDON
FACILITY TYPE:
775
ADDRESS:
5720 LABATH AVE, SUITE B & C
TELEPHONE:
(707) 585-1991
CITY:
ROHNERT PARK
STATE:
CA
ZIP CODE:
94928
CAPACITY:
60
CENSUS:
DATE:
04/25/2023
TYPE OF VISIT:
Collateral
UNANNOUNCED
TIME BEGAN:
11:28 AM
MET WITH:
Landon Vandergriend (Administrator)
TIME COMPLETED:
12:31 PM
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Licensing Program Analyst (LPA) Marisol Cuadra conducted an unannounced collateral visit to the Day Program and met with Landon Vandergriend (Administrator). The purpose of this collateral visit is to conduct confidential interviews with participant (P1) regarding complaints unrelated to this facility.
No deficiencies cited during today's inspection.
SUPERVISORS NAME
:
Bethany Moellers
LICENSING EVALUATOR NAME
:
Marisol Cuadra
LICENSING EVALUATOR SIGNATURE
:
DATE:
04/25/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/25/2023
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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