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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804141
Report Date: 06/09/2023
Date Signed: 06/09/2023 11:25:09 AM

Document Has Been Signed on 06/09/2023 11:25 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:MILLS MANORFACILITY NUMBER:
496804141
ADMINISTRATOR:KUEHNHACKL, ANTONFACILITY TYPE:
735
ADDRESS:9790 OCONNELL RDTELEPHONE:
(707) 824-8403
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY: 6CENSUS: 4DATE:
06/09/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:04 AM
MET WITH:Anton Kuehnhackl (Applicant)TIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced for the purpose of conducting a subsequent pre-licensing visit to review the physical plant for non-ambulatory status. LPA was greeted by Applicant Anton Kuehnhackl. A pre-licensing inspection was completed on 04/25/2023.

During today's visit, LPA/Applicant toured the facility, including bedroom #3 that has the non-ambulatory status. No new construction was done. The bedroom was previously designated as non-ambulatory room and was approved per fire safety inspection on May 30, 2023 for capacity of 4 ambulatory and 2 non-ambulatory residents. Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulation. LPA will notify Application Unit Pre-licensing inspection is complete to proceed with the process of license. Pre-Licensing fire clearance correction have been resolved. Pre-Licensing is now complete.

No deficiencies noted at the time of this visit in the areas toured by LPA. Exit interview conducted with Applicant and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2023
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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