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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804187
Report Date: 02/05/2024
Date Signed: 02/05/2024 12:08:49 PM

Document Has Been Signed on 02/05/2024 12:08 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:COTTONWOOD COMMUNITY SUPPORT HOMEFACILITY NUMBER:
496804187
ADMINISTRATOR:HAYES, TESS R.FACILITY TYPE:
735
ADDRESS:411 COTTONWOOD DR.TELEPHONE:
(707) 623-8025
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 4CENSUS: 4DATE:
02/05/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Tess Hayes, Applicant/Administrator
Sheena Helems, Co-Administrator		TIME COMPLETED:
12:00 PM
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Component II completion: Successful

Facility Type: Adult Residential Facility (ARF)
Application Type: Change in Ownership (CHOW)
Capacity: 4
Census (if any clients in care): 4
COMP II Participants: Tess Hayes, Applicant/Administrator
Sheena Helems, Co-Administrator
Interview Method: Virtual interview (Microsoft Teams)

On February 5, 2024 at 11:00 AM, applicant and 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 that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22.

During COMP II, CAB analyst confirmed Applicant and Administrator’s understanding of following areas:
1. Facility Operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing Requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General Provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing Readiness

Exit interview conducted with Applicant and Administrator. Report sent via email and informed to return sign copy to CAB by end of business day today.
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 02/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2024
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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