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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801881
Report Date: 06/09/2022
Date Signed: 06/09/2022 09:39:28 AM


Document Has Been Signed on 06/09/2022 09:39 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:SAINT MARY HOMECAREFACILITY NUMBER:
496801881
ADMINISTRATOR:HABTU, ASTERFACILITY TYPE:
740
ADDRESS:5039 PARKHURST DRIVETELEPHONE:
(707) 539-6677
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:4CENSUS: 0DATE:
06/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Rafael HabtezionTIME COMPLETED:
09:45 AM
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Licensing Program Analyst (LPA) Erik Gonzalez-Campos arrived unannounced at Saint Mary Homecare for a voluntary facility Closure, and met with Rafael Habtezion. Licensee, Aster Habtu was made aware and agreed to closure inspection over the phone.

The Licensee notified Community Care Licensing of intent to close this facility on May 16, 2022 via email and a letter. Copies of letters given to residents were reviewed.

The licensee initiated this facility closure. LPA inspected all rooms and the exterior of the building and found no evidence that would suggest that clients are residing on the premises. All clothing and personal items belonging to clients have been removed. Clients that were living in the home were relocated to other properties in Sonoma County on May 31st.

Licensee has provided physical copy of license to Community Care Licensing. Facility will be closed effective June 10, 2022. A copy of this report was printed for Licensee.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022
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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