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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
496801932
Report Date:
09/08/2022
Date Signed:
09/08/2022 11:53:48 AM
Document Has Been Signed on
09/08/2022 11:53 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:
DUNGARVIN CALIFORNIA LLC
FACILITY NUMBER:
496801932
ADMINISTRATOR:
FAIRCHILD, CARRIE
FACILITY TYPE:
775
ADDRESS:
433-439 BEAVER ST
TELEPHONE:
(707) 543-5895
CITY:
SANTA ROSA
STATE:
CA
ZIP CODE:
95404
CAPACITY:
75
CENSUS:
16
DATE:
09/08/2022
TYPE OF VISIT:
Collateral
UNANNOUNCED
TIME BEGAN:
11:18 AM
MET WITH:
Carrie Fairchild (Administrator)
TIME COMPLETED:
12:08 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct interviews regarding complaints unrelated to this facility and met with Carrie Fairchild, Administrator.
No deficiencies cited during today's inspection.
SUPERVISORS NAME
:
Bethany Moellers
LICENSING EVALUATOR NAME
:
Marisol Cuadra
LICENSING EVALUATOR SIGNATURE
:
DATE:
09/08/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/08/2022
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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