Facility Evaluation Report

Capacity: 6 (5 non-ambulatory and 1 bedridden)

COMP II Participants: Thang Duong, Licensee and Myrna Bugasto, Administrator

On December 2, 2021 at 9:00 AM , Licensee and Administrator participated in COMP II via telephone with Analyst, Celia Phomphachanh from CAB. Identification of the Licensee and Administrator was verified by providing California Driver License number verbally. During COMP II, Licensee and Administrator confirmed the understanding of Title 22 and Health and Safety Codes. Component II was successfully completed. Licensee and Administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB.

During COMP II, CAB Analyst confirmed Licensee and Administrator’s understanding of following areas:

1. Facility Operation: Licens e type, client/resident populations, and program

2. Staff Qualifications and r esponsibilities

3. Applicant and Administrator Qualifications

4. Program Policy: Abuse, admission agreement, medication management, reporting incidents to CCL,

5. Grievances, Complaints, Community resources

7. Application Document Review and Technical Assistance: Criminal Record Clearance, Health

Screening, Fire Clearance, First Aid/CPR Certificate, Administrator Certificate, Financial Verification,

Pre-licensing Inspection, Compliance History and Control of property.

Interviewed concluded with Licensee and Administrator. LIC 809 will be sent via email PDF to Administrator.