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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
496803049
Report Date:
11/05/2021
Date Signed:
11/05/2021 04:55:50 PM
Document Has Been Signed on
11/05/2021 04:55 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:
VARENNA AT FOUNTAINGROVE
FACILITY NUMBER:
496803049
ADMINISTRATOR:
BUOT, FERDINAND
FACILITY TYPE:
741
ADDRESS:
1401 FOUNTAINGROVE PKWY
TELEPHONE:
(707) 526-1226
CITY:
SANTA ROSA
STATE:
CA
ZIP CODE:
95403
CAPACITY:
322
CENSUS:
236
DATE:
11/05/2021
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
03:15 PM
MET WITH:
Administrator, Ferdinand Buot
TIME COMPLETED:
05:10 PM
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Licensing Program Analyst Erik Gonzalez-Campos conducted a Case Management visit today to interview resident and review records.
No citations were issued.
SUPERVISORS NAME
:
Kimberley Mota
LICENSING EVALUATOR NAME
:
Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE
:
DATE:
11/05/2021
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/05/2021
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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