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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577005397
Report Date: 11/09/2023
Date Signed: 11/09/2023 12:19:11 PM

Document Has Been Signed on 11/09/2023 12:19 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:HARMONY DAY PROGRAMFACILITY NUMBER:
577005397
ADMINISTRATOR:VENTIMIGLIA, DOMINICFACILITY TYPE:
775
ADDRESS:1250 HARTER AVE, STE GTELEPHONE:
(530) 666-6146
CITY:WOODLANDSTATE: CAZIP CODE:
95776
CAPACITY: 30CENSUS: 17DATE:
11/09/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:04 PM
MET WITH:Patty Mendoza, Program ManagerTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted the Annual Unannounced Inspection on 11/09/2023 and completed the Care Tool, which was reviewed with Program Manager, Patty Mendoza.

Inspection was completed and found no deficiencies and no citations were issued.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2023
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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