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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
496803698
Report Date:
12/31/2024
Date Signed:
12/31/2024 11:24:23 AM
Document Has Been Signed on
12/31/2024 11:24 AM
- 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:
VINEYARD AT FOUNTAINGROVE, THE
FACILITY NUMBER:
496803698
ADMINISTRATOR/
DIRECTOR:
SANDHU,RAJVIR
FACILITY TYPE:
740
ADDRESS:
200 FOUNTAINGROVE PKWY
TELEPHONE:
(707) 544-4909
CITY:
SANTA ROSA
STATE:
CA
ZIP CODE:
95403
CAPACITY:
64
TOTAL ENROLLED CHILDREN:
0
CENSUS:
28
DATE:
12/31/2024
TYPE OF VISIT:
POC
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:
Serina Barredo
TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst Leibert returns today for a proof of correction visit regarding a deficiency that was cited on 10/08/2024 regarding electrical problems in four residents' rooms. LPA toured the facility and noted that the electrical problems have been resolved and the deficiency is cleared.
Report left.
Carla Martinez
TELEPHONE:
(707) 588-5059
David Leibert
TELEPHONE:
(707) 588-5086
DATE:
12/31/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/31/2024
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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