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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803576
Report Date: 11/22/2024
Date Signed: 11/22/2024 04:27:37 PM

Document Has Been Signed on 11/22/2024 04:27 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SLEEPY HOLLOW ASSISTED LIVINGFACILITY NUMBER:
496803576
ADMINISTRATOR/
DIRECTOR:
ARTHUR ALCONESFACILITY TYPE:
740
ADDRESS:3707 SLEEPY HOLLOW DRIVETELEPHONE:
(707) 953-2161
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 6CENSUS: 4DATE:
11/22/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:45 PM
MET WITH:ARTHUR ALCONES, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
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At approximately 3:45PM, Licensing Program Analysts (LPA) LPA Loera and LPA Frank, arrived unannounced to conduct a Case Management - Other Visit and met with Licensee/Administrator, Arthur Alcones. The purpose of the visit is to confirm an Order to Individual for Immediate Exclusion for All Facilities.

The Department delivered an "immediate exclusion" notice on 11/22/2024 to facility. Per notice, Staff Member 1 (S1) and Staff Member 2 (S2) cannot be allowed to work, be present and/or live in a CCL licensed facility, or have contact with residents in any residential facility or child day care licensed by the California Department of Social Services. Therefore, the Department orders the facility to remove S1 and S2 from any contact with residents and not allow these employees to be physically present in the facility.

Licensee/Administrator informed LPA that S1 and S2 will be removed from the facility and from the facility's staff roster. Licensee/Administrator stated they understood the notice.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Licensee/Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024
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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