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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803579
Report Date: 01/28/2025
Date Signed: 01/28/2025 05:10:26 PM

Document Has Been Signed on 01/28/2025 05:10 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BENSHANTE PLACEFACILITY NUMBER:
496803579
ADMINISTRATOR/
DIRECTOR:		MILLER, DEBBIEFACILITY TYPE:
735
ADDRESS:500 LOS ARBOLES WAYTELEPHONE:
(707) 978-5989
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 4CENSUS: DATE:
01/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:28 PM
MET WITH:Debbie Miller-AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:25 PM
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Licensing Program Analyst (LPA) Alviso conducted a Required - 1 Year Inspection, and met with Licensee/Administrator Debbie Miller. There are four clients in care.

Fire clearance approval is for four (4) ambulatory. Facility has an infection control plan as required. Facility has an emergency disaster plan as required. Fire extinguishers one (1), was serviced and tagged as required, dated 12/10/24. All exits were cleared and free of obstruction.

This annual will be continued by the LPA at a later date.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
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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