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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570317743
Report Date: 09/07/2023
Date Signed: 09/07/2023 02:30:12 PM

Document Has Been Signed on 09/07/2023 02:30 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:DAVIS SUMMER HOUSEFACILITY NUMBER:
570317743
ADMINISTRATOR:MICHAEL YUEN-HURWITZFACILITY TYPE:
735
ADDRESS:2525 EAST 8TH STREETTELEPHONE:
(530) 757-1294
CITY:DAVISSTATE: CAZIP CODE:
95618
CAPACITY: 14CENSUS: 13DATE:
09/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Gloria Lane-Ricafrente, Assistant Program Manager TIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an inspection and investigate an incident report received. LPA met with Gloria Lane-Ricafrente, Assistant Program Manager.

LPA found the facility to be clean, well-organized and a comfortable temperature. There were 5 staff and 13 residents at the time of inspection.

Residents were involved in their routines; with some returning from their day programs. Staff was helping residents prepping lunches for the following day.

LPA collected documents and conducted interviews.

There were no deficiencies found at the time of inspection. No citations issued.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2023
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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