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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201395
Report Date: 07/30/2024
Date Signed: 07/31/2024 02:31:57 PM


Document Has Been Signed on 07/31/2024 02:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRALIZED APP UNIT, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:DAPHNE CARE HOMEFACILITY NUMBER:
079201395
ADMINISTRATOR:RAMANDANES, ANGIE MFACILITY TYPE:
740
ADDRESS:116 DAPHNE COURTTELEPHONE:
(510) 978-4254
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:6CENSUS: 0DATE:
07/30/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:licensee/administrator Angie RamandanesTIME COMPLETED:
10:30 AM
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Facility Type: RCFE
Application Type: Initial
Capacity: 6
Census (if any clients in care): N/A
COMP II Participants: Angie Ramandanes, licensee/administrator
Interview Method: Telephone interview

On 7/30/2024, 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 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
following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISOR'S NAME: Amy AveryTELEPHONE: (916) 651-7841
LICENSING EVALUATOR NAME: Vanessa ContrerasTELEPHONE: (916) 651-7900
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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