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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803825
Report Date: 10/13/2021
Date Signed: 10/16/2021 11:57:19 AM

Document Has Been Signed on 10/16/2021 11:57 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:VINE RIDGE AT CLOVERDALEFACILITY NUMBER:
496803825
ADMINISTRATOR:UBALLEZ, DAVIDFACILITY TYPE:
740
ADDRESS:247 TREADWAY DRIVETELEPHONE:
(707) 791-4787
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY: 58CENSUS: 21DATE:
10/13/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:David UballezTIME COMPLETED:
11:00 AM
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Licensing Program Analyst Leibert arrived unannounced for the purpose of following up on proof of correction for a citation that was issued on 9/16/2021 and required staff training. LPA met with the administrator and discussed the POC. Mr. Uballez stated that he had submitted proof of completion on 9/30/21 and provided proof that it was sent. LPA assumes the email was misplaced or deleted by mistake and will accept the proof provided by the Administrator. Citation for 87465(h((2) issued on 9/16/2021 is cleared.


No citations issued today.
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2021
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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