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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570301295
Report Date: 08/08/2023
Date Signed: 08/08/2023 11:03:27 AM

Document Has Been Signed on 08/08/2023 11:03 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: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: 12DATE:
08/08/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Samantha Young, AdministratorTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to verify that individual (I1) was not on the premises and not working at the facility.

Interview with Administrator and Human Resources for the organization verified that the individual (I1) is not an employee at the facility, and has not been an employee since 09-14-2017, and is not eligible for rehire.

No deficiencies found at the time of inspection.
No citations issued.

Exit interview conducted with Administrator.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2023
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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