Facility Evaluation Report

Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit. LPA Martinez met with Christine Torres and explained the purpose of the visit.

The purpose of the visit today, is in response to a change of Administrator and a corporation change- LIC 200 application follow up. LPA Martinez informed Christine Torres an LIC 200 application will need to be submitted to the Centralized Application Bureau (CAB), and LPA Martinez provided CAB's website and telephone number information.

https://www.cdss.ca.gov/inforesources/community-care/ascp-centralized-application-units

https://www.cdss.ca.gov/cdssweb/entres/forms/English/LIC200.pdf

Christine reported she is working on submitting the LIC 200 application to CAB. In addition, the following Administrator documentation will need to be submitted to CCLD:

LIC 200 from licensee requesting administrator Change

Board Resolution for new administrator if corporation

LIC 308 Designation of Facility Responsibility

An exit interview was conducted, and a copy of this report was provided to Christine.