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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570316115
Report Date: 10/20/2022
Date Signed: 10/20/2022 09:49:34 AM

Document Has Been Signed on 10/20/2022 09:49 AM - 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: 85DATE:
10/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Janice Birdwell, Office ManagerTIME COMPLETED:
09:55 AM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced for a case management visit. LPA was greeted at door by receptionist who took the LPA's temperature and asked Covid-19 screening questions and asked LPA to sign visitor's log before allowing entry to the facility.

The LPA met with Janice Birdwell, Office Manager, to review Guardian requirements and guidelines and went through updates of the facility's LIC500 and active personnel. There were some name changes which needed updating. There were no other concerns found with staffing.

Facility was clean and orderly, Some residents were outside; others were in the dining room enjoying breakfast, as well as in their rooms.

No deficiencies were found at the time of inspection. No citations issued.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2022
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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