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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801600
Report Date: 07/15/2024
Date Signed: 07/15/2024 02:35:07 PM


Document Has Been Signed on 07/15/2024 02:35 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:MT. VERNON GARDENSFACILITY NUMBER:
496801600
ADMINISTRATOR:DELLER, EMILCE & KIMFACILITY TYPE:
740
ADDRESS:3754 MT. VERNON RD.TELEPHONE:
(707) 829-3796
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY:6CENSUS: 6DATE:
07/15/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:17 PM
MET WITH:Emilce Deller (Licensee)TIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management Visit and met with Licensee, Emilce Deller.

On 6/24/24 the licensee have contacted the Department requesting guidance regarding an increase of capacity from six to seven residents. During today's visit, LPA/Licensee have discussed about the possibility of increasing capacity and after the conversation, the licensee stated that they don't want to proceed with the change of capacity process. Also, Licensee requested LPA some guidance regarding possible cost of living increases effective next year. LPA have provided regulations regarding increases and Licensee agreed to submit to the Department any changes prior to become effective for residents in care and their responsible parties. LPA discussed with Licensee Technical Support Program (TSP) that offers advice, guidance, a review of facility operation, discusses best practice, and required regulation/HSC compliance if needed.

No deficiencies cited during today's visit.

Exit interview was conducted with Licensee and a copy of this report was given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2024
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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