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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570316115
Report Date: 02/08/2022
Date Signed: 02/15/2022 12:00:44 PM

Document Has Been Signed on 02/15/2022 12:00 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:CALIFORNIAN, THEFACILITY NUMBER:
570316115
ADMINISTRATOR:KATHY B. NEESERFACILITY TYPE:
740
ADDRESS:1224 COTTONWOOD STREETTELEPHONE:
(530) 666-2433
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY: 130CENSUS: DATE:
02/08/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Kathy Neeser, AdministratorTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Nakagawa arrived unannounced on February 8, 2022 at approximately 3:10 PM to conduct a case management and met with Administrator Kathy Neeser.
The purpose of today's inspection was to ensure the facility received Stipulation and Waiver; and Order (CDSS No. 8121113101) dated January 28, 2022 for Staff (S1). A copy of the Stipulation was provided to the Administrator. LPA went over the terms of probation per the Stipulation and Administrator stated they understood the terms.

No deficiencies cited at today’s inspection.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2022
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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