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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496890049
Report Date: 05/03/2021
Date Signed: 05/03/2021 03:14:11 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:EXCEPTIONAL CARE HOMEFACILITY NUMBER:
496890049
ADMINISTRATOR:JONES, RICHARDFACILITY TYPE:
740
ADDRESS:393 BONNIE AVENUETELEPHONE:
(707) 205-1228
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:6CENSUS: DATE:
05/03/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:59 PM
MET WITH:Licensee Richard JonesTIME COMPLETED:
03:23 PM
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Licensing Program Analyst Willis arrived unannounced and met with Licensee, Richard Jones.

Upon arrival Licensee was moving furniture out of facility. LPA conducted a walk through of the facility and observed that all rooms were vacated and there were no residents in care. All personal items of residents and Licensee has been removed from the facility. Bedroom furniture had been removed from all rooms as well.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2021
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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