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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209323
Report Date: 06/02/2023
Date Signed: 06/02/2023 09:14:03 AM

Document Has Been Signed on 06/02/2023 09:14 AM - 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:SEQUOIA GROVE ASSISTED LIVING, INCFACILITY NUMBER:
107209323
ADMINISTRATOR:KEGHOUHY HANDIANFACILITY TYPE:
740
ADDRESS:787 E. MINARETS AVETELEPHONE:
(559) 449-1249
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY: 6CENSUS: DATE:
06/02/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Keghouhy Handian (LICENSEE/ADMINISTRATOR) TIME COMPLETED:
09:11 AM
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Component II completion: Successful
Facility Type: RCFE
Application Type: CHOW
Capacity: 6
Census (if any clients in care): YES
COMP II Participants: Keghouhy Handian (LICENSEE/ADMINISTRATOR)
Interview Method: Telephone interview
Virtual interview (Skype, Go To Meeting, etc)
In-person interview (Headquarter conference room)
On [04/25/23], Keghouhy Handian (LICENSEE/ADMINISTRATOR) participated in COMP II for the below pending facilities: SEQUOIA GROVE ASSISTED LIVING INC-#107209318]. Identification of the applicant(s) and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant(s) 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

SUPERVISORS NAME: Jude De La Concepcion
LICENSING EVALUATOR NAME: Maria Ejaz
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2023
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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