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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803340
Report Date: 10/07/2021
Date Signed: 10/07/2021 10:52:00 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:NAZARETH AGUA CALIENTE VILLAFACILITY NUMBER:
496803340
ADMINISTRATOR:RAGLAND, SHANTIFACILITY TYPE:
740
ADDRESS:17250 VAILETTITELEPHONE:
(707) 996-6100
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY:45CENSUS: 0DATE:
10/07/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator, Shanti RaglandTIME COMPLETED:
11:05 AM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrive unannounced at 10:15 AM to conduct a voluntary closure inspection and met with administrator Shanti Ragland.

Administrator provided copies of the closure plan and copies of the letters given to the residents and their responsible parties on 08/16/2021. On 10/01/2021, administrator notified LPA that all residents had been relocated. On 10/06/2021, administrator provided relocation roster to LPA.

The licensee initiated this facility closure. LPA inspected all rooms and the exterior of the building and found no evidence that would suggest that residents are residing on the premises. All furniture, clothing and personal items belonging to residents have been removed. Residents that were living in the facility were relocated to other properties in Sonoma, Napa, Marin, and Siskiyou Counties.

Administrator provided license to LPA. Facility will be closed effective October 08, 2021. Exit interview was conducted and a copy of this report was given to the Administrator, Shanti Ragland.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
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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