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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570316115
Report Date: 09/04/2024
Date Signed: 09/04/2024 03:26:57 PM

Document Has Been Signed on 09/04/2024 03:26 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:
09/04/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:50 PM
MET WITH:Kathy Neeser, Co-AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:26 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced for a case management visit. LPA met with Kathy Neeser, to review incident of resident R1 leaving the facility unattended. Facility was clean, orderly and a comfortable temperature.

LPA and Administrator discussed staffing additions that have occurred and additional trainings that will occur to ensure the safety and well-being of residents. Related deficiencies were cited in a complaint investigation during same visit. No other citations issued.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2024
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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