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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801902
Report Date: 03/07/2025
Date Signed: 03/07/2025 02:45:41 PM

Document Has Been Signed on 03/07/2025 02:45 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BROWN STREET HOUSEFACILITY NUMBER:
496801902
ADMINISTRATOR/
DIRECTOR:		GILLION, CHRISTINAFACILITY TYPE:
735
ADDRESS:112 BROWN STREETTELEPHONE:
(707) 568-5204
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 15CENSUS: 14DATE:
03/07/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:10 PM
MET WITH:Administrator, Emiley MidyetteTIME VISIT/
INSPECTION COMPLETED:
02:55 PM
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At approximately 02:10 PM, Licensing Program Analyst (LPA) Ali Deniz and Licensing Program Manager (LPM) Victoria Bertozzi arrived unannounced to conduct to case management inspection.

CCL staff arrived to follow-up regarding a recent unexpected death in the facility. CCL staff spoke with staff and a client and obtained documents. Administrator agreed to obtain the Death Certificate for client, C1 and send to CCL.

No deficiencies cited during this inspection.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2025
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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