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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801754
Report Date: 04/04/2023
Date Signed: 04/04/2023 01:40:34 PM


Document Has Been Signed on 04/04/2023 01:40 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:WHITE ROSE MANORFACILITY NUMBER:
496801754
ADMINISTRATOR:REMOLLO-SANTOS, GEORGIANAFACILITY TYPE:
740
ADDRESS:313 SHEILA COURTTELEPHONE:
(707) 776-0858
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:6CENSUS: 6DATE:
04/04/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Glenda CastleTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced case management inspection and met with designee Glenda Castle. The purpose of this case management inspection is to follow up on Technical Advisories given at Annual Inspection on 1/17/2023 and follow up visit on 2/13/2023.

During annual inspection LPA gave facility a LIC9102 TA for not having window screens on 2 windows. LPA conducted follow up visit on 2/13/2023 observing still no screens, LPA giving 2 weeks to fix.

On today's 4/4/2023 inspection LPA observed facility has replaced screens. (see LIC812).

There were no deficiencies cited at this time.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023
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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