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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804039
Report Date: 02/22/2022
Date Signed: 02/22/2022 01:25:37 PM


Document Has Been Signed on 02/22/2022 01:25 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:WILLOW GLENFACILITY NUMBER:
496804039
ADMINISTRATOR:TEETER, ZOEFACILITY TYPE:
740
ADDRESS:2540 SUMMERFIELD ROADTELEPHONE:
(707) 479-5577
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY:6CENSUS: 0DATE:
02/22/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Zoe Teeter-ApplicantTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA), Alviso conducted a pre-licensing inspection, and met with applicant Zoe Teeter, to continue the inspection.

LPA toured the home with the applicant. LPA observed the backyard to have a large wood deck/patio and walk way that leads out to the front of the house; This deck/patio may be used for wheelchair access, walkers, canes, all ambulatory and nonambulatory persons, this area may be used to exit all residents if needed from the backyard area of the home.

Applicant to revise the backyard/outside of the home sketch, and the LPA will ensure a fire clearance inspection request is sent out for re-inspection due to the new wooden deck/patio, and ramp.

LPA observed some items needing to be completed, including the clean-up of the backyard from items, debris, and tools, from the renovation of the backyard area. Applicant Zoe Teeter agreed to submit pictures of these items once complete.

Once all items are reviewed for completeness, the LPA will forward reports to the assigned Application Analysts in our Department; The Application Analyst will notify the Applicant of the status of the application.

The applicant will notify the LPA no later than March 1, 2022.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2022
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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