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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803796
Report Date: 05/04/2023
Date Signed: 05/04/2023 03:18:08 PM


Document Has Been Signed on 05/04/2023 03:18 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:WILLOW GLEN HOMEFACILITY NUMBER:
496803796
ADMINISTRATOR:FLORES INEZ M.FACILITY TYPE:
740
ADDRESS:4750 COUNTRY CLUB DRTELEPHONE:
(707) 708-2199
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:6CENSUS: 5DATE:
05/04/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Zoe Teeter-LicenseeTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alviso conducted a case management visit, on 5/4/23 at approximately 2:00pm, and met with Licensee Zoe Teeter, and Administrator Inez Flores.

LPA was conducting the visit to inspect the facility layout inside, and outside against the current facility sketch revised back on 3/14/2019. The sketch received on 3/14/2019, was sent to the local Rohnert Park Fire Department(RPFD), and received a fire clearance approval from the Fire Inspector Jim Thompson.

The inspection today, 5/4/23, review of records, current fire clearance approval, revised sketch, and obtained documentation from the Licensee, revealed that the facility has no renovation changes to the facility layout since the last fire clearance approval dated 3/15/2019.

There are no deficiencies cited today.
Exit interview conducted with the Licensee Zoe Teeter, and the Administrator Inez Flores.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023
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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