Facility Evaluation Report
Capacity6
Census6
Date signed05/28/2025 12:19:05 PM
Name of licensing program analystCheyenne Ratajczak
Name of licensing program managerLaura Munoz
On 05/28/2025 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a case management visit regarding an incident report and death report that the department received on 05/26/2025 . LPA met with Staff Mariam Soumahoro and explained the purpose of the visit.
The purpose of the visit is to gather more information regarding an incident and death report Community Care Licensing (CCL) received on 05/26/2025.
LPA obtained a copy of R1's LIC602 and ID page.
Exit interview conducted and a copy of the report and LIC809G was left at the facility.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction