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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803924
Report Date: 08/11/2022
Date Signed: 08/11/2022 10:58:27 AM


Document Has Been Signed on 08/11/2022 10:58 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:SONOMAMODELXFACILITY NUMBER:
496803924
ADMINISTRATOR:FLORES, MARIAFACILITY TYPE:
740
ADDRESS:765 DONALD STREETTELEPHONE:
(415) 264-5486
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY:32CENSUS: 20DATE:
08/11/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Licensee's Alexander Varshavsky and Julia LatifiTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced Case Management inspection to this facility and met with Julia Latifi, Licensee who arrived at 8:45 AM. The purpose of today’s inspection is to amend LIC 809/809C/809C-2/809-D from Annual inspection conducted on 8/9/2022.

LPA issued citations 87355(e)(1) Criminal Record Clearance for 3 staff not being fingerprint cleared & 87355(e)(2) transfer of criminal record clearance or association to facility for 1 staff not being associated. Upon further review, LPA arrived today to issue civil penalties for citations issued on 8/9/2022. Civil Penalties in the amount of $300.00 and $100.00 are being assessed.

See Amended 809/809C/809C-2/809-D from Annual inspection 8/9/2022

LPA requested copy of current LIC500 Personnel list & LIC 9020 Resident list

LPA obtained requested POC from Licensee and cleared POC. licensee understands all staff must be background cleared and associated to facility prior to returning to work or working or more civil penalties will be assessed.

No deficiencies cited during today’s inspection.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
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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