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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801807
Report Date: 12/17/2021
Date Signed: 12/17/2021 01:52:17 PM

Document Has Been Signed on 12/17/2021 01:52 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:YERBA BUENA RESIDENTIAL CARE HOMEFACILITY NUMBER:
496801807
ADMINISTRATOR:MARTINEZ, ANGELICAFACILITY TYPE:
740
ADDRESS:5200 YERBA BUENATELEPHONE:
(707) 539-6780
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 6CENSUS: DATE:
12/17/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Staff, Maira ZamoraTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct a case management inspection at approximately 1:00 PM. The purpose of the inspection was to follow up with an incident report received by community care licensing on December 6, 2021.

Incident report indicated that a resident, R1 had been transported to the hospital. Administrator was not present at the time of the inspection. Administrator and LPA spoke over the phone. Administrator indicated that R1 was still at the hospital and would be returning back to the facility later this week. Administrator will let LPA know when R1 returns. LPA reviewed R1's file.


No deficiencies cited during today's inspection.

Exit interview conducted with staff. LPA unable to print. LPA will email copy of this report to licensee.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2021
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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