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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803766
Report Date: 05/20/2022
Date Signed: 05/20/2022 11:41:24 AM

Document Has Been Signed on 05/20/2022 11:41 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:AZALEA HOUSEFACILITY NUMBER:
236803766
ADMINISTRATOR:AYALA, ALMIDAFACILITY TYPE:
740
ADDRESS:209 AZALEA CIRTELEPHONE:
(707) 964-4940
CITY:FORT BRAGGSTATE: CAZIP CODE:
95437
CAPACITY: 4CENSUS: 4DATE:
05/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Adam AshfordTIME COMPLETED:
11:55 AM
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At approximately 10:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit. LPA met with Director Adam Ashford and toured the facility. The facility was clean and orderly and at a comfortable temperature. All staff were wearing masks and following their infection control protocols. The purpose of this visit is to follow up on a death report sent to CCL. There were 2 clients and 2 staff present in the facility. Facility followed all protocols and reporting requirements.

LPA discussed the infection control procedures of the facility and the new infection control policy that will be submitted to CCL when completed.

No citations issued.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2022
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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