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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803412
Report Date: 04/28/2022
Date Signed: 04/28/2022 12:51:54 PM


Document Has Been Signed on 04/28/2022 12:51 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:SUNRISE OF PETALUMAFACILITY NUMBER:
496803412
ADMINISTRATOR:LAYTON, NATHANFACILITY TYPE:
740
ADDRESS:815 WOOD SORREL DRTELEPHONE:
(707) 776-2885
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:95CENSUS: 76DATE:
04/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Nathan LaytonTIME COMPLETED:
12:51 PM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced case management and met with Nathan Layton - Administrator. The purpose of the case management visit was to obtain additional information regarding a recent incident and SOC 341 that occurred on 4/11/2022 that was self reported by the facility.


LPA has asked questions, acquire documentation, and requested more information for residents in question. (see LIC 812s)


No deficiencies cited during todays inspection.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
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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