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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 572700713
Report Date: 01/06/2021
Date Signed: 01/06/2021 01:57:55 PM

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:CAREWELL AT COTTONWOOD, LLCFACILITY NUMBER:
572700713
ADMINISTRATOR:CHENG, JULIANAFACILITY TYPE:
740
ADDRESS:1106 COTTONWOOD COURTTELEPHONE:
(530) 759-1234
CITY:DAVISSTATE: CAZIP CODE:
95618
CAPACITY:6CENSUS: 6DATE:
01/06/2021
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
11:12 AM
MET WITH:Paulin PantigTIME COMPLETED:
01:15 PM
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Licensing Program Analysts (LPAs) Katrina Walters and Alicia Delmundo, conducted a tele-visit on 1/6/2021 at 11:12 AM with this facility to conduct a collateral visit. LPAs spoke with House Manager, Paulin Pantig. This visit is being done by tele-visit, due to COVID-19 precautions. The purpose of this visit collateral is to gather information unrelated to this facility.

No deficiencies cited.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2021
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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