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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803428
Report Date: 03/04/2020
Date Signed: 03/04/2020 04:24:06 PM

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:MUIR WOOD ADOLESCENT AND FAMILY SERVICESFACILITY NUMBER:
496803428
ADMINISTRATOR:SOWLE, SCOTTFACILITY TYPE:
730
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:10CENSUS: 9DATE:
03/04/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Maura SangsterTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) David Hiett made an unannounced case management inspection, and met with Director of Operations Maura Sangster. The purpose of the inspection was regarding a Caregiver Background Check Bureau notice regarding an exemption denial. Based on evidence obtained during today's visit, LPA Hiett has verified the individual (S1) (see LIC 811 dated 3/4/2020) is not present, employed or residing at the facility and will not be returning to facility.

No deficiencies observed or cited during this inspection. A copy of this report left with the licensee.

Verification of removal is complete.
SUPERVISOR'S NAME: Zaid HakimTELEPHONE: (707) 320-3944
LICENSING EVALUATOR NAME: David HiettTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2020
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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