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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804113
Report Date: 01/13/2023
Date Signed: 01/13/2023 11:15:58 AM

Document Has Been Signed on 01/13/2023 11:15 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:FOUNTAINGROVE LODGEFACILITY NUMBER:
496804113
ADMINISTRATOR:MOONEY, SHAWNFACILITY TYPE:
741
ADDRESS:4210 THOMAS LAKE HARRIS DRIVETELEPHONE:
(707) 576-1101
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 173CENSUS: DATE:
01/13/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:59 AM
MET WITH:Shawn MooneyTIME COMPLETED:
11:15 AM
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Facility Type: Residential Care Facility for the Elderly - Continuing Care Retirement Community
Application Type: Change of Ownership
Capacity: 173
Census (if any clients in care): 133
COMP II Participants: Shawn Mooney
Interview Method: Telephone interview
On January 13, 2023, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained.
During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restricted/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Jude De La Concepcion
LICENSING EVALUATOR NAME: Bethany Hunter
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2023
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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