Facility Evaluation Report

Application Type: CHOW (change in ownership)

Census (if any clients in care): 5 (1 ambulatory, 1 bedridden and 3 non-ambulatories)

On November 19, 2021 at 9:00 AM , Administrator participated in COMP II via telephone with Analyst, Celia Phomphachanh from CAB. Identification of the Licensee was verified by providing California Driver License number verbally. During COMP II, Applicant confirmed the understanding of Title 22 and Health and Safety Codes. Component II was successfully completed. Administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB.

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

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

2. Staff Qualifications and responsibilities

3. Applicant and Administrator Qualifications

4. Program Policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions

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 Administrator. LIC 809 will be sent via email PDF to Administrator.