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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803317
Report Date: 10/31/2023
Date Signed: 12/20/2023 12:28:32 PM

Document Has Been Signed on 12/20/2023 12:28 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:CICADA-GREENBRAEFACILITY NUMBER:
216803317
ADMINISTRATOR:CAMATOG, NOELFACILITY TYPE:
730
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 6CENSUS: 6DATE:
10/31/2023
TYPE OF VISIT:Case Management - MedicationsUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Noel CamatogTIME COMPLETED:
03:00 PM
NARRATIVE
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An unannounced SB 484 Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Cheyenne McCambridge on the above date at 10:30 AM. During the inspection, LPA McCambridge met with Administrator Noel Camatog.

LPA reviewed Zero child’s records on site at the facility due to none of the clients being dependent foster care children.

LPAs reviewed zero child’s psychotropic medications and medication records.

LPA interviewed zero clients due to them being non-verbal and non-dependent foster care children.

LPA interviewed two of staff on site starting at 12:00 pm.

LPA reviewed two of staff personnel files on site at the facility.

LPA toured of the facility inside and out.

LPA provided the Summary Report to Noel Camatog, Administrator upon completion.

No deficiencies are being cited at this time. LPA conducted exit interview with Administrator Noel Camatog.
SUPERVISORS NAME: Isabel Diego
LICENSING EVALUATOR NAME: Cheyenne McCambridge
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2023
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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