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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803860
Report Date: 01/12/2023
Date Signed: 01/12/2023 05:51:02 PM


Document Has Been Signed on 01/12/2023 05:51 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:CLEARWATER AT SONOMA HILLSFACILITY NUMBER:
496803860
ADMINISTRATOR:ORTIZ, JUSTINE M.FACILITY TYPE:
740
ADDRESS:710 ROHNERT PARK EXPRESSWAY ETELEPHONE:
(707) 710-7385
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:114CENSUS: 89DATE:
01/12/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Kathleen McCaarron-VP of OperationsTIME COMPLETED:
06:00 PM
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Licensing Program Analyst(LPA) Dina Alviso, conducted a case management inspection, and met with Kathleen McCarron, Vice President of Operations.

The case management inspection is being conducted to review a resident incident and obtain more information.

LPA reviewed resident and staff records. LPA requested specific documentation from record reviews; VP Kathleen provided copies to the LPA as requested during today's inspection.

There are no deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023
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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