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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804140
Report Date: 03/20/2025
Date Signed: 03/20/2025 12:07:19 PM

Document Has Been Signed on 03/20/2025 12:07 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:FREMONT HOUSEFACILITY NUMBER:
496804140
ADMINISTRATOR/
DIRECTOR:		THOMAS, DOMONIQUEFACILITY TYPE:
735
ADDRESS:2120 FREMONT DRTELEPHONE:
(707) 542-1595
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 6CENSUS: 4DATE:
03/20/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Domonique Thomas, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:22 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Case Management visit and was greeted by caregiver. Administrator Domonique Thomas not available to come to facility. .

Today, 3/20/25, LPA conducted a case management to amend the LIC9099 issued in relation to complaint #21-AS-20250307140033.

The LIC9099 was amended to remove the two [2] allegations listed that were found to be substantiated (Personal Rights and Staff did not provide adequate meals to clients in care). The LIC9099 listed the allegations found to be unsubstantiated (Staff left clients unattended and Facility is not sanitary), but LPA accidentally listed all four [4] of the allegations in the complaint, two of which were found to be substantiated. The LIC9099A listed the substantiated allegations.

Allegations listed on the original LIC9099:


Personal Rights
Staff left clients unattended
Staff did not provide adequate meals to clients in care
Facility is not sanitary

Allegations listed on the amended LIC9099:
**amended to remove substantiated allegations**
Staff left clients unattended
Facility is not sanitary

Exit interview conducted with caregiver and a copy of this report was given.

No deficiencies cited.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
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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