<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803499
Report Date: 12/29/2021
Date Signed: 12/29/2021 12:18:25 PM

Document Has Been Signed on 12/29/2021 12:18 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:SILVER STARFACILITY NUMBER:
496803499
ADMINISTRATOR:KUMAR, AMIFACILITY TYPE:
740
ADDRESS:1966 DENNIS LANETELEPHONE:
(707) 595-3605
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 6CENSUS: 6DATE:
12/29/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Licensee/Administrator Ami KumarTIME COMPLETED:
12:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) conducted a case management and met with Administrator /Licensee Ami Kumar, and Administrator Janine Sorrenson.

LPA is conducting the case management to review a recently submitted resident incident report. LPA reviewed facility resident file, and obtained information regarding the incident. Licensee/Administrator Ami K and Administrator Janine are addressing the incident as required. All parties have been contacted as required. All reports were completed and submitted as required.

Licensee/Administrator has agreed to submit requested documentation no later than 12/31/21.

No deficiencies cited today.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1