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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803933
Report Date: 06/16/2023
Date Signed: 06/16/2023 02:10:41 PM


Document Has Been Signed on 06/16/2023 02:10 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:ST. MICHAEL ASSISTED LIVINGFACILITY NUMBER:
496803933
ADMINISTRATOR:CARDENAS, CRISANTE MFACILITY TYPE:
740
ADDRESS:804 ST. FRANCIS STTELEPHONE:
(707) 763-8289
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:6CENSUS: 0DATE:
06/16/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Licensee Marilyn GreenTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Hansen was at facility delivering complaint findings and met with Marilyn Green, Licensee to complete a final walk through for Licensee-initiated Facility closure. LPA arrived and was granted access by Licensee. LPA/Licensee toured the facility.

LPA inspected all rooms and the exterior of the building today and found no evidence that would suggest that any residents are residing on the premises. All clothing and personal items belonging to residents have also been removed.

Licensee turned over copy of License during today’s inspection. The license is closed and no longer valid, effective today, 6/16/2023. LPA will send out a forfeiture letter to Licensee and complete closure process.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023
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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