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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 086804160
Report Date: 07/24/2023
Date Signed: 07/24/2023 12:40:22 PM

Document Has Been Signed on 07/24/2023 12:40 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
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:GLEN HAVEN DAY PROGRAMFACILITY NUMBER:
086804160
ADMINISTRATOR:HALL, JACOBFACILITY TYPE:
775
ADDRESS:680 E. WASHINGTON BLVDTELEPHONE:
(707) 954-3113
CITY:CRESCENT CITYSTATE: CAZIP CODE:
95531
CAPACITY: 30CENSUS: 0DATE:
07/24/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Jacob Hall, LicenseeTIME COMPLETED:
12:35 PM
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Component II completion: Successful

Facility Type: Adult Day Program (ADP)
Application Type: Change in Ownership (CHOW)
Capacity: 30
Census (if any clients in care): 13
COMP II Participants: Jacob Hall, Licensee
Interview Method: Telephone interview

On July 24, 2023 at 11:50AM, Licensee participated in COMP II. Identification of the Licensee was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Licensee 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.

During COMP II, CAB analyst confirmed Licensee's understanding of following areas:
1. Facility Operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing Requirements & Training: Ratio. Licensee indicated 2:1 client/staff ratio.
4. Restrictive/Prohibited Health Conditions
5. General Provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing Readiness

Exit interview conducted with Licensee. Copy of report sent via email and informed to return sign copy back to CAB by end of business today.
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2023
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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