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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 175001941
Report Date: 11/10/2022
Date Signed: 11/10/2022 10:30:27 AM

Document Has Been Signed on 11/10/2022 10:30 AM - 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:A NICE CARE HOMEFACILITY NUMBER:
175001941
ADMINISTRATOR:GAMBONINI, CHERYLFACILITY TYPE:
740
ADDRESS:6784 CRUMP AVENUETELEPHONE:
(707) 274-9938
CITY:NICESTATE: CAZIP CODE:
95464
CAPACITY: 6CENSUS: 4DATE:
11/10/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Cheryl Gambonini - LicenseeTIME COMPLETED:
10:35 AM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced case management inspection and met with Cheryl Gambonini, Licensee. The purpose of this case management inspection is to follow up on the submission of facilities mandatory Infection Control Plan.

The Licensee informed LPA the facility has not submitted an infection control plan as of yet. LPA informed the facility that the licensee was granted a waiver under the Authority of Governor Newsom’s Executive Order N-11-22 issued on June 17, 2022, and the licensee agreed to submit the Infection Control Plan by 12/10/2022. LPA has given a facility a Technical Assistance at today’s visit (see LIC 9102TA).

No deficiencies cited during today’s inspection.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2022
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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