Facility Evaluation Report, 05/04/2023 — Faithful Home of Rossmoor, a, Rossmoor CA

Facility Evaluation Report

Faithful Home of Rossmoor, a, Rossmoor05/04/2023Licence 306006317

Capacity6

Census0

Date signed05/08/2023 02:05:19 PM

The inspector’s account

COMP II Participants: Theresa Kholoma, Applicant/Administrato r

On May 4, 2023, 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/ administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of the

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

4. Restrictive/Prohibited Health Conditions

Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction