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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803966
Report Date: 03/10/2022
Date Signed: 03/10/2022 04:04:35 PM

Document Has Been Signed on 03/10/2022 04:04 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:WOODWARD ASSISTED LIVINGFACILITY NUMBER:
496803966
ADMINISTRATOR:AMADOR, ADAFACILITY TYPE:
740
ADDRESS:1825 WOODWARD DR.TELEPHONE:
(530) 308-6230
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 6CENSUS: 1DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Administrator, Jackie (Ada) AmadorTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced at approximately 3:20 PM on on 3/10/2022 to conduct a Required - 1 Year Inspection. LPA was greeted by administrator, Jackie (Ada) Amador.

Upon arrival administrator informed LPA that there is only one resident in care who is also the owner of the house and that there are currently no plans to take more residents. LPA spoke with licensee over the phone who confirmed the plans. If this changes, licensee will inform community care licensing. Currently all but one bedrooms are empty.

Exit interview conducted with administrator, and a copy of this report printed for the facility
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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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