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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803290
Report Date: 10/25/2022
Date Signed: 10/25/2022 02:36:29 PM

Document Has Been Signed on 10/25/2022 02:36 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:HAZEL HOMEFACILITY NUMBER:
496803290
ADMINISTRATOR:MILLER, DEBBIEFACILITY TYPE:
735
ADDRESS:537 LOS ALTOS CTTELEPHONE:
(707) 843-4880
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 6CENSUS: 5DATE:
10/25/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Licensee Debbie MillerTIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced case management inspection and met with Debbie Miller, Licensee . The purpose of this case management inspection is to follow up on the submission of facilities mandatory Infection Control Plan.

The licensee informed LPA the facility had submitted an infection control plan but may have gone to a wrong email. LPA informed the facility that the licensee was granted a waiver under the Authority of Governor Newsom’s Executive Order N-11-22 issued on June 17, 2022, and the licensee agreed to submit the Infection Control Plan by June 30, 2022. LPA was able to obtain a copy of the facilities Infection Control Plan at today's visit along with the signed addendum for the Monkeypox Infection Control.

No deficiencies cited during today’s inspection.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2022
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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