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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
570314689
Report Date:
08/09/2021
Date Signed:
09/15/2021 11:15:45 AM
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
101 GOLF COURSE DR. STE. A-230
ROHNERT PARK
,
CA
94928
FACILITY NAME:
SACRED HEART CARE HOME FOR THE ELDERLY
FACILITY NUMBER:
570314689
ADMINISTRATOR:
DAVIS, ARVIN
FACILITY TYPE:
740
ADDRESS:
605 CONNOR LANE
TELEPHONE:
(530) 662-6055
CITY:
WOODLAND
STATE:
CA
ZIP CODE:
95695
CAPACITY:
8
CENSUS:
4
DATE:
08/09/2021
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
01:55 PM
MET WITH:
Ed David
TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Angela Elliott arrived uannounced to this facility to conduct a case management. LPA reviewed training records.
SUPERVISOR'S NAME:
Bethany Moellers
TELEPHONE:
(707) 588-5026
LICENSING EVALUATOR NAME:
Angela Elliott
TELEPHONE:
(470) 717-1668
LICENSING EVALUATOR SIGNATURE:
DATE:
08/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/09/2021
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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