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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496890075
Report Date: 09/19/2023
Date Signed: 09/19/2023 09:37:13 AM

Document Has Been Signed on 09/19/2023 09:37 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:BECOMING INDEPENDENTFACILITY NUMBER:
496890075
ADMINISTRATOR:JAMES COXFACILITY TYPE:
775
ADDRESS:1745 COPPERHILL PARKWAYTELEPHONE:
(707) 524-6670
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 100CENSUS: 12DATE:
09/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:31 AM
MET WITH:Stephanie Rodriguez (Service Director)TIME COMPLETED:
09:52 AM
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Licensing Program Analysts (LPAs) Cuadra and Coppo arrived unannounced to conduct this Case Management Visit to amend a report originally dated 09/14/2023. LPAs met with Stephanie Rodriguez (Service Director).

The document requires amending because annual was conducted in the wrong location of the facility. Report was amended and signed today, 9/19/2023.

No citations were issued during this visit.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2023
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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