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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804107
Report Date: 08/17/2023
Date Signed: 08/17/2023 04:00:22 PM

Document Has Been Signed on 08/17/2023 04:00 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:NIGHTINGALE CARE HOMES LLCFACILITY NUMBER:
496804107
ADMINISTRATOR:BOTONES, ANNA KARINAFACILITY TYPE:
740
ADDRESS:5161 OAK MEADOW DRIVETELEPHONE:
(415) 341-7649
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 6CENSUS: 6DATE:
08/17/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:17 PM
MET WITH:Cassie Guerrero (Lead Staff)TIME COMPLETED:
03:45 PM
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Licensing Program Analysts (LPAs) Cuadra and Coppo arrived unannounced to conduct a case management subsequent pre-licensing process initiated by a change of ownership. LPA was greeted by Cassie Guerrero (Lead Staff). Current Administrator Anna Botones was unable to come to the facility, but were available by phone and gave authorization for staff to sign the report.

During today's visit, LPAs had difficulty issues with laptop and had to return to CCL's office to draft the report. Administrator was informed and LPAs/lead staff toured the facility and observed the area under construction. LPA obtained construction permit issued by the City of Santa Rosa approval date of 7/20/23.

Deficiency observed by LPAs/staff will be cited on current license #496803416: Personal Accommodations. Outdoor passageways, ramp located at back door exit was observed with couple mattresses and bedroom furniture including bed rails. LPA will submit copy of the facility report to the Centralized Application Unit and inform of citations. Component III was completed.

No deficiencies cited during today's inspection visit. An exit interview was conducted via phone with Administrator and a copy of this report was emailed due to technical issues.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2023
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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