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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803759
Report Date: 08/10/2023
Date Signed: 08/10/2023 03:09:06 PM


Document Has Been Signed on 08/10/2023 03:09 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:NATASHA'S HOMEFACILITY NUMBER:
496803759
ADMINISTRATOR:GLENN VARGASFACILITY TYPE:
740
ADDRESS:3365 PETALUMA HILL RDTELEPHONE:
(650) 270-3030
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY:3CENSUS: 3DATE:
08/10/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Licensee, Leonardo Dela CruzTIME COMPLETED:
03:15 PM
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Licensing Program Analyst Bertozzi arrived unannounced to conduct a Case Management inspection and met with Licensee, Leonardo Dela Cruz.

The purpose of this visit is to amend the complaint report dated 7/26/2023 as the date on the report is incorrect. The correct date is 7/26/2022

No deficiencies cited during inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023
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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