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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
496803339
Report Date:
04/24/2024
Date Signed:
04/24/2024 04:56:47 PM
Document Has Been Signed on
04/24/2024 04:56 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:
DATE:
04/24/2024
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME BEGAN:
04:00 PM
MET WITH:
Robert Alvarado-Administrator
TIME COMPLETED:
05:15 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 more information on a resident incident recently reported to the Department by the facility.
LPA reviewed resident (R1) incident records. Administrator provided additional information to the LPA.
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:
04/24/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/24/2024
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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