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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803825
Report Date: 09/28/2021
Date Signed: 09/28/2021 02:00:10 PM

Document Has Been Signed on 09/28/2021 02:00 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:VINE RIDGE AT CLOVERDALEFACILITY NUMBER:
496803825
ADMINISTRATOR:UBALLEZ, DAVIDFACILITY TYPE:
740
ADDRESS:247 TREADWAY DRIVETELEPHONE:
(707) 791-4787
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY: 58CENSUS: 19DATE:
09/28/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:David UballezTIME COMPLETED:
02:00 PM
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Licensing Program Analyst Leibert arrived unannounced for the purpose of following up on citations issued on 9/16/2021. Specifically, training for staff in the area of medical and dental care was agreed upon to clear the deficiency. Administrator stated that all but one staff has completed the training. The staff has been out on an approved leave but will return this week. Administrator will forward proof of completed training for all staff by the end of this week, 10/01/2021.

No deficiencies cited this visit.

Administrator advised that failure to clear deficiency by 10/012021 may result in civil penalties.
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2021
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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