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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804138
Report Date: 01/24/2023
Date Signed: 01/24/2023 02:30:08 PM

Document Has Been Signed on 01/24/2023 02:30 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:TAKING THE JOURNEY NORTHFACILITY NUMBER:
496804138
ADMINISTRATOR:ERIKSEN, KELLYFACILITY TYPE:
740
ADDRESS:2125 MCSWEEN LNTELEPHONE:
(707) 338-8812
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 6CENSUS: 0DATE:
01/24/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Kelly Eriksen, Administrator/Applicant
Kisa Doss, Applicant/Licensee		TIME COMPLETED:
02:20 PM
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Component II completion: Successful

Facility Type: Residential Care Facility for Elderly (RCFE)
Application Type: Initial
Capacity: 6
Census (if any clients in care): 0
COMP II Participants: Kelly Eriksen, Administrator/Applicant
Kisa Doss
Interview Method: Telephone interview

On January 24, 2023 at 1:25 PM, Applicant and Administrator participated in COMP II. Identification of the Applicant and Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22.

During COMP II, CAB analyst confirmed Applicant and Administrator’s understanding of following areas:
1. Facility Operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing Requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General Provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing Readiness

Exit interview conducted with Administrator and Applicant. Copy of report sent via email and informed to return to CAB by close of business today.
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2023
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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