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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570316115
Report Date: 08/07/2024
Date Signed: 08/07/2024 03:05:21 PM

Document Has Been Signed on 08/07/2024 03:05 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/
DIRECTOR:		KATHY B. NEESERFACILITY TYPE:
740
ADDRESS:1224 COTTONWOOD STREETTELEPHONE:
(530) 666-2433
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY: 130CENSUS: 87DATE:
08/07/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Fernando Valadez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:05 PM
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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 asked LPA to sign visitor's log before allowing entry to the facility.

The LPA met with Fernando Valadez, Administrator, and toured the facility to inspect the facility and observe staffing and review records. The facility was found to be clean and orderly. Lunch was observed and residents expressed their satisfaction in the menu, including desserts. Several activities were observed during visit.

No citations issued at the time of inspection.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2024
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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