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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803759
Report Date: 07/27/2023
Date Signed: 07/27/2023 02:41:13 PM

Document Has Been Signed on 07/27/2023 02:41 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:NATASHA'S HOMEFACILITY NUMBER:
496803759
ADMINISTRATOR:GLENN VARGASFACILITY TYPE:
740
ADDRESS:3365 PETALUMA HILL RDTELEPHONE:
(650) 270-3030
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 3CENSUS: 3DATE:
07/27/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator, Glenn VargasTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and met with Administrator, Glenn Vargas.

This visit is a continuance of the Annual Inspection that was initiated on June 22.2023.

Fire extinguishers were serviced during this inspection. Facility has hardwired combination Smoke/Carbon Monoxide detectors located throughout the facility that were tested and operational. Fire doors were functional during test. Most recent fire/disaster drill was conducted June 21, 2023.

Three staff files were reviewed. Staff have required First Aid and CPR certificates. Administrator Certificate for Administrator, Glenn Vargas 6026688740 expires 8/17/2023. Medications and medication records were reviewed as well as staff training. Client P&I was also reviewed.

No deficiencies cited during inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2023
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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