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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803960
Report Date: 04/03/2024
Date Signed: 04/03/2024 03:42:29 PM


Document Has Been Signed on 04/03/2024 03:42 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:ELSA'S HOMEFACILITY NUMBER:
496803960
ADMINISTRATOR:HUMPHREY, NICHOLASFACILITY TYPE:
740
ADDRESS:10 CREEKVIEW COURTTELEPHONE:
(707) 539-5625
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:6CENSUS: 5DATE:
04/03/2024
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Nicholas Humphrey, Licensee via telephoneTIME COMPLETED:
03:56 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Caregiver. Caregiver (S1) arrived later. Licensee and Administrator of record, Nicholas Humphrey was out of town and not available. LPA reached Licensee by phone. At conclusion of inspection per S1, caregiver has permission/authority to sign CCL report. S1 was present via telephone for exit interview.

LPA has been working with Licensee since December 12, 2023, with on going correspondence both via email and telephone, to change facility Administrator to S1. S1 has been acting as both caregiver and Administrator. S1 works NOC shift and per submitted LIC500 for Admin change, S1 was identified to work M-Th 10pm-6am and Friday 8am-5pm. LPA advised Admin of CCL's concern of how S1 would be able to fulfill the specified Administrator duties per Title 22 regulation 87405 working one day per week during business hours. Per email communication on 3/29/2024 from Licensee to CCL, they have chosen a different Admin candidate other than S1, so that S1 will remain the NOC shift employee. Licensee advised CCL that they would be sending a new LIC500 to reflect the changes and new Admin. Licensee is also that current Administrator of record, however their Admin certificate is neither active nor pending. Per Title 22 regulation 87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator (deficiency cited, see 809D).

Upon LPA arrival at facility today, Licensee advised LPA via telephone that now they have sold the home and closed escrow as of this week (week of 4/1/2024) and they intend to complete a change of ownership for the facility. LPA advised Licensee that until the applicant that has applied with CCL is approved and licensed as the current licensee and approved as Administrator they will continue:
  • as the licensee and Admin of the facility
  • to be responsible for the operation of the facility and plan of operation
  • to be in control of the property
  • to be responsible for the staffing of all caregivers and staff, including all staff training, resident care, and all maintenance of the facility will continue under their name

Continued on 809C...
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ELSA'S HOME
FACILITY NUMBER: 496803960
VISIT DATE: 04/03/2024
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Continued from 809...

Also, LPA advised Licensee per Title 22 regulation 87224(5)(A) and 87224(5)(A)(1) when there is a (5) Change of use of the facility. (A) The licensee may, upon no less than sixty (60) days written notice, evict a resident due to change of use of the facility. 1. In addition to written notice to quit requirements specified in Section 87224(d), written notice to evict due to change of use of the facility shall be made to the resident or the resident’s responsible person and shall include all requirements specified in Section 1569.682(a)(2)(A) through (F) of the Health and Safety Code. Licensee to provide CCL with copy of aforementioned notice immediately.

At approximately 9:30am LPA and S1 toured the building and grounds. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food in kitchen was found to be stored in a safe manner with open items covered. Kitchen cabinet containing cleaning supplies was locked. However, cleaning toxins, bleach, and laundry supplies located in the garage were accessible to residents as the door to the garage was not locked, both upon LPA arrival and periodically during LPA visit to facility. LPA advised S1 and caregiver that door must remain locked at all times. Per Title 22 regulation 87309(a) Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients (deficiency cited, see 809D). Additionally, food supplies, pantry items, and refrigerated items are also stored in the garage, not separated from cleaning supplies. Per Title 22 regulation 87555 General Food Service Requirements (b)The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies (deficiency cited, see 809D).

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were in good repair. Extra hygiene products and linens were available. Water temperatures in sinks accessible to residents in care measured at 115.8 and 114.9 degrees F which is within the allowable range of 105 to 120 degrees F. One resident bathroom had required bath mat and grab bar; however per LPA and S1 observation, mat has black spots covering much of the surface area underneath. The other resident bathroom did not have required bath mat. In bedroom #2 the window screen is missing. Trash bins in bathrooms are missing lids. Broken mirror in backyard has sharp edges and LPA advised to immediately discard.

Continued on 809C(2)...
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ELSA'S HOME
FACILITY NUMBER: 496803960
VISIT DATE: 04/03/2024
NARRATIVE
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continued from 809C...

Per Title 22 regulation 87303(a) 87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors (deficiency cited, see 809D).

Per LPA and S1 observation as well as caregivers, resident room #6 (R6) has strong odor of urine. LPA observed chair in R6's room that had very strong smell of urine as well as R6's bed. Per Title 22 regulation 87625(b)(3) Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence (deficiency cited, see 809D).

Fire extinguishers were last inspected 1/22/2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and serviced Jan 2024. Facility has a backup generator for use during a power outage. Per LPA and S1 observation, exit path identified as emergency exit path on side of facility is obstructed by 3 large garbage cans. Per Title 22 regulation 87202(a) Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department (deficiency cited, see 809D). Per S1, facility has not conducted a fire drill in quite some time. Per Health and Safety Code (HSC)1569.695(c) A facility shall conduct a drill at least quarterly for each shift…Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill (deficiency cited, see 809D).

At approximately 1:00pm LPA conducted a review 5 staff records. Staff members S2, S3, and S4 did not have Health screens. Per Title 22 regulation 87411 Personnel Requirements - General (f) All personnel, including the licensee and administrator, shall be in good health…Good physical health shall be verified by a health screening…A report shall be made of each screening, signed by the examining physician….(deficiency cited, see 809D).


Continued on 809C(3)...
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC809 (FAS) - (06/04)
Page: 3 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ELSA'S HOME
FACILITY NUMBER: 496803960
VISIT DATE: 04/03/2024
NARRATIVE
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Continued from 809C(2)...

At approximately 1:30pm LPA conducted a review 5 resident records. All required documentation current and present, including respective hospice plans.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:



LIC500- Personnel Report
LIC308- Designation of Responsibility
All required documentation for Change of Ownership and Change of Administrator

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with S1 via telephone and present caregiver and a copy of this report was given.

SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 04/03/2024 03:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: ELSA'S HOME
FACILITY NUMBER: 496803960

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
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Based on LPA and S1 observation, the licensee did not comply with the section cited above in that exit path identified as emergency exit path on side of facility is obstructed by 3 large garbage cans, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2024
Plan of Correction
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Facility to make exit path identified as emergency exit path on side of facility entirely unobstructed. Facility to submit pictures of cleared path to CCL by POC due date.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and S1 observation, the licensee did not comply with the section cited above inthat cleaning toxins, bleach, and laundry supplies located in the garage were accessible to residents as the door was not locked upon LPA arrival and remained periodically during LPA inspection, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2024
Plan of Correction
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Facility to keep door to garage locked at all times. Facility to submit LIC9098 self-certifying that door remains locked at all times by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
LIC809 (FAS) - (06/04)
Page: 5 of 9


Document Has Been Signed on 04/03/2024 03:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: ELSA'S HOME
FACILITY NUMBER: 496803960

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above in that staff members S2, S3, and S4 did not have Health screens which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2024
Plan of Correction
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Facility to submit to CCL Health Screens for S2, S3, and S4 by POC due date

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
LIC809 (FAS) - (06/04)
Page: 6 of 9


Document Has Been Signed on 04/03/2024 03:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: ELSA'S HOME
FACILITY NUMBER: 496803960

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and S1 observation the licensee did not comply with the section cited above in that one required bath mat had black spots covering much of the surface area underneath the mat and the other bathroom did not have required bath mat at all. In room #2 the window screen is missing. Trash bins in bathrooms are missing lids, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2024
Plan of Correction
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4
Facility to submit pictures of required bath mats present in repsective bathrooms, window screen present in room #2, and that all trash bins in bathrooms have tight fitting lids. Facility to submit pictures by POC due date.
Type B
Section Cited
CCR
87555(b)(25)
General Food Service Requirements
(b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and S1 observation, the licensee did not comply with the section cited above in that food supplies, pantry items, and refrigerated items were stored in garage, not separated from cleaning supplies which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2024
Plan of Correction
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2
3
4
Facility to ensure all cleaning supplies are stored separately from any and all food items. Facility to submit pictures of garage after separating food items from cleaning supplies. Cleaning supplies to be stored inaccessible to residents. Facility to submit pictures by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
LIC809 (FAS) - (06/04)
Page: 7 of 9


Document Has Been Signed on 04/03/2024 03:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: ELSA'S HOME
FACILITY NUMBER: 496803960

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation, S1 interview and LPA attempted record review, the licensee did not comply with the section cited above in that the facility has not condicted a fire drill in quite some time, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2024
Plan of Correction
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2
3
4
Facility to conduct disaster/emergancy drills per the above Health and Safety Code. Facility to submit LIC9098 self-certifying they have conducted the drills with each staff, for each shift, and will continue to do so every quarter. Facility to submit LIC9098 by POC due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
LIC809 (FAS) - (06/04)
Page: 8 of 9


Document Has Been Signed on 04/03/2024 03:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: ELSA'S HOME
FACILITY NUMBER: 496803960

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(a)
87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA interview and record review, the licensee did not comply with the section cited above in that the Licensee is also current Administrator, however their Administrator certificate is neither active nor pending, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2024
Plan of Correction
1
2
3
4
Facility to submit written plan indicating plan for implementation and start date of qualified and certified administrator. Plan to be submitted to CCL LPA by POC due date of 4/24/2024
Type B
Section Cited
CCR
87625(b)(3)
87625(b)(3) Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA, S1, and caregivers observation, the licensee did not comply with the section cited above in that resident room #6 (R6) has strong odor of urine. LPA and S1 observed chair in R6's room that had very strong smell of urine as well as R6's bed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2024
Plan of Correction
1
2
3
4
Facility to submit LIC9098 self-certifying that the R6's room and carpet has been cleaned, chair removed and replaced, and that bed is free from urine smell by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
LIC809 (FAS) - (06/04)
Page: 9 of 9