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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570300654
Report Date: 02/08/2022
Date Signed: 02/08/2022 02:29:18 PM

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:ST. JOHN'S RETIREMENT VILLAGE/MANORFACILITY NUMBER:
570300654
ADMINISTRATOR:SCHARBACH, WILLIAMFACILITY TYPE:
740
ADDRESS:135 WOODLAND AVENUETELEPHONE:
(530) 662-1290
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY:174CENSUS: DATE:
02/08/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:13 PM
MET WITH:Bill Scharbach, AdministratorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Nakagawa arrived unannounced on this date, February 8, 2022 at approximately 2:15 PM to conduct a case management and met with Administrator Bill Scharbach.
The purpose of today's inspection was to ensure the facility received Stipulation and Waiver; and Order (CDSS No. 8121113101) dated January 28, 2022 for Staff (S1). A copy of the Stipulation was provided to the Administrator who stated they understood the terms.

LPA reviewed the facilities personnel report and confirmed with the Administrator that S1 is no longer employed with the facility.

No deficiencies cited at today’s inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022
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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