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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209230
Report Date: 06/06/2022
Date Signed: 06/06/2022 02:01:32 PM


Document Has Been Signed on 06/06/2022 02:01 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:STANFORD COTTAGE ASSISTED LIVINGFACILITY NUMBER:
107209230
ADMINISTRATOR:VASQUEZ, MARTHAFACILITY TYPE:
740
ADDRESS:2202 STANFORD AVETELEPHONE:
(858) 342-4998
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: DATE:
06/06/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Benjamin Carter-CEO; Martha Vasquez-AdministratorTIME COMPLETED:
01:49 PM
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Facility Type: RCFE
Application Type: CHOW
Capacity: 6
Census: 4
COMP II Participants: Benjamin Carter, CEO; Martha Vasquez, Administrator
Interview Method: Telephone interview

On 6/6/22, 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 the understanding of the California Code Title 22 Regulations. 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: Mirella QuarantaTELEPHONE: (916) 657-2025
LICENSING EVALUATOR NAME: Anna BarriosTELEPHONE: (916) 651-7817
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2022
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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