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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
496803339
Report Date:
02/07/2023
Date Signed:
02/07/2023 04:50:35 PM
Document Has Been Signed on
02/07/2023 04:50 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:
BROOKDALE PAULIN CREEK
FACILITY NUMBER:
496803339
ADMINISTRATOR:
ALVARADO, ROBERT
FACILITY TYPE:
740
ADDRESS:
2375 RANGE AVE
TELEPHONE:
(707) 575-3722
CITY:
SANTA ROSA
STATE:
CA
ZIP CODE:
95403
CAPACITY:
100
CENSUS:
63
DATE:
02/07/2023
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME BEGAN:
02:40 PM
MET WITH:
Robert Alvarado-Administrator
TIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Alviso arrived unannounced to conduct a Case Management inspection and met with Administrator Robert Alvarado.
This case management is being conducted to obtain information on a resident incident recently reported to the Department by the facility.
LPA reviewed facility and resident records. Administrator provided additional staff information to the LPA. Administrator provided additional information to the LPA regarding the incident.
No deficiencies cited today.
SUPERVISOR'S NAME:
Hope DeBenedetti
TELEPHONE:
(707) 588-5059
LICENSING EVALUATOR NAME:
Dina Alviso
TELEPHONE:
(707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE:
02/07/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/07/2023
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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