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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801807
Report Date: 11/15/2023
Date Signed: 11/15/2023 12:11:30 PM


Document Has Been Signed on 11/15/2023 12:11 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:YERBA BUENA RESIDENTIAL CARE HOMEFACILITY NUMBER:
496801807
ADMINISTRATOR:MARTINEZ, ANGELICAFACILITY TYPE:
740
ADDRESS:5200 YERBA BUENATELEPHONE:
(707) 539-6780
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:6CENSUS: 6DATE:
11/15/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Licensee, Angelica MartinezTIME COMPLETED:
12:15 PM
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An Informal Meeting with Licensing Program Manager, Bethany Moellers, Licensing Program Analyst (LPA), Farhaan Sarangi and Licensee/Administrator, Angelica Martinez was held for the purpose of discussing a document issued by Santa Rosa Fire Department that was determined to be modified. Licensee denied the verbiage that was added to the document and confirmed the shed located in the backyard of the facility is used for storage only. CCL will continue to collaborate with Santa Rosa Fire Department and Code Enforcement to resolve the issue.

No citations issued during todays informal meeting.

SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023
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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