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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804133
Report Date: 07/31/2023
Date Signed: 07/31/2023 04:17:45 PM


Document Has Been Signed on 07/31/2023 04:17 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:RINCON VALLEY ASSISTED LIVING LLCFACILITY NUMBER:
496804133
ADMINISTRATOR:GURJA, FIKREFACILITY TYPE:
740
ADDRESS:996 ESTES DR.TELEPHONE:
(707) 235-8007
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:6CENSUS: 1DATE:
07/31/2023
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Licensee/Administrator, Fikre Gurja
Caregiver, Rahel Gurja		TIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived announced at Rincon Valley Assisted Living LLC for the purpose of conducting a Case Management-Other Inspection. LPA was greeted at the front door by Caregiver, Rahel Gurja and was granted access into the facility.

During this Case Management-Other inspection, LPA amended an LIC 809-Pre-Licensing inspection report dated for July 24, 2023.

No deficiencies were observed or cited during today's Case Management-Other Inspection. Exit interview was conducted and a copy of this report was given to the facility Caregiver.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2023
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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