Facility Evaluation Report

Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care):5 COMP II Participants: Medina, Allen (Administrator and Corporate Board Member) and Nepomuceno, Maricel (Corporate Board Member)

On 3/1/2022, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:

1. Facility operation: License type, client/resident populations, and program

4. Restrictive/Prohibited Health Conditions