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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570301295
Report Date: 08/16/2022
Date Signed: 08/16/2022 03:03:15 PM

Document Has Been Signed on 08/16/2022 03:03 PM - 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:SUMMER HOUSE INC.FACILITY NUMBER:
570301295
ADMINISTRATOR:YOUNG, SAMANTHAFACILITY TYPE:
735
ADDRESS:206 5TH STTELEPHONE:
(530) 662-8493
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY: 12CENSUS: 11DATE:
08/16/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Sam Young, AdministratorTIME COMPLETED:
03:10 PM
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LIcensing Program Analyst (LPA) Jill Nakagawa arrived unannounced at Summer House, Inc. to conduct an inspection of the facility and check on eviction proceedings due to a resident's change in condition.

LPA met with Administrator, Sam Young, at approximately 12:50 PM, who showed LPA around the facility. The facility was clean and orderly and free of odors. The kitchen had just been fully stocked with a shopping trip by staff and residents. Residents' rooms were clean and tidy, with cleaning and laundry done by the residents with staff support. The living room was also clean. Staff and administration are working to keep facility hygienically clean.

LPA conducted a review of documentation regarding the eviction, as well as observation of the resident and facility.

There were no deficiencies at the time of the inspection.

No citations issued.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2022
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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