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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
570300654
Report Date:
04/28/2022
Date Signed:
04/28/2022 10:10:32 AM
Document Has Been Signed on
04/28/2022 10:10 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/MANOR
FACILITY NUMBER:
570300654
ADMINISTRATOR:
SCHARBACH, WILLIAM
FACILITY TYPE:
740
ADDRESS:
135 WOODLAND AVENUE
TELEPHONE:
(530) 662-1290
CITY:
WOODLAND
STATE:
CA
ZIP CODE:
95695
CAPACITY:
174
CENSUS:
0
DATE:
04/28/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
09:00 AM
MET WITH:
Bill Scharbach, Administrator
TIME COMPLETED:
10:18 AM
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Licensing Program Analysts (LPAs) Jill Nakagawa and Chris Arnhold arrived unannounced to complete an inspection on St. John's for final closure of the facility. LPAs met with Administrator Bill Scharbach. LPAs conducted a final inspection and found there were no residents receiving care or supervision. A relocation list of residents was provided by Administrator.
Licensee understands they will need to reapply and obtain a new license if you wish to operate a Residential Care Facility for the Elderly or a Community Care Facility again.
Closure of this facility has been finalized. Facility was closed effective 04/25/2022.
LPA took possession of the physical license.
No citations issued.
SUPERVISOR'S NAME:
Kimberley Mota
TELEPHONE:
(707) 588-5051
LICENSING EVALUATOR NAME:
Jill Nakagawa
TELEPHONE:
707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE:
04/28/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/28/2022
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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