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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804280
Report Date: 12/12/2024
Date Signed: 12/13/2024 03:29:34 PM

Document Has Been Signed on 12/13/2024 03:29 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:ARBOL RESIDENCES OF SANTA ROSAFACILITY NUMBER:
496804280
ADMINISTRATOR/
DIRECTOR:		RIDENOUR,JASMINEFACILITY TYPE:
740
ADDRESS:300 FOUNTAINGROVE PARKWAYTELEPHONE:
(877) 295-3747
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 152CENSUS: DATE:
12/12/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:KARINA TAPIA, QUINTIN KINGTIME VISIT/
INSPECTION COMPLETED:
09:29 AM
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Facility Type: Residential Care Facility for the Elderly
Application Type: Change of Ownership
Capacity: 110
Census (if any clients in care): 91
COMP II Participants: KARINA TAPIA, QUINTIN KING
Interview Method: Telephone interview

On December 12, 2024, 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: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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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