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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570300654
Report Date: 03/01/2022
Date Signed: 03/01/2022 11:52:43 AM


Document Has Been Signed on 03/01/2022 11:52 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: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:
03/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Janet Martinez, Marketing/Placement ManagementTIME COMPLETED:
12:00 PM
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LIcensing Program Analyst Jill Nakagawa arrived unannounced to check on the closure process of St. John's Retirement Village. LPA met with Janet Martinez (JM), Marketing and Placement Manager to discuss the closure process. Eviction and Closure Notices went out to residents and their POA's on 2/25/22. As of this date, according to JM, all but three (3) residents have notified the office about their future residences.
No one has expressed any undue hardship or lack of supports or resources.

Final day of operation at this point is April 25, 2022, unless all residents move out prior to that date.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2022
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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