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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803289
Report Date: 09/25/2023
Date Signed: 09/25/2023 02:45:06 PM

Document Has Been Signed on 09/25/2023 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BEACHWOOD HOUSE, INC.FACILITY NUMBER:
496803289
ADMINISTRATOR:CABIE, BENJAMINFACILITY TYPE:
735
ADDRESS:1177 BEACHWOOD DRIVETELEPHONE:
(707) 332-9865
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 4CENSUS: 4DATE:
09/25/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Jhanell Edmalin (House Manager)TIME COMPLETED:
03:00 PM
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Licensing Program Analysts (LPAs) Cuadra and Coppo arrived at facility unannounced to conduct a case management and met with House Manager Jhanell Edmalin to follow up on outstanding fees in the amount of $681.

During today's visit, LPAs discussed with House Manager regarding the outstanding late fees. Per House Manager, they already submitted payment for the outstanding $681 to avoid further late fee penalties.

No deficiencies cited during today's visit.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2023
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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