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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209377
Report Date: 11/17/2023
Date Signed: 11/17/2023 01:20:56 PM

Document Has Been Signed on 11/17/2023 01:20 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:BURLINGTON, THEFACILITY NUMBER:
157209377
ADMINISTRATOR:GIBSON, KALAFACILITY TYPE:
740
ADDRESS:13 SYCAMORE DRTELEPHONE:
(415) 810-0145
CITY:WOFFORD HEIGHTSSTATE: CAZIP CODE:
93285
CAPACITY: 21CENSUS: DATE:
11/17/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:TIME COMPLETED:
01:12 PM
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COMP II by CAB successfully completed

Facility Type: RCFE
Application Type: CHOW
Capacity: 21
Census (if any clients in care): 20
Method: Telephone call with CAB
COMP II Participants: Kala Gibson, Administrator; Anthony Barbato, Owner; Shannon Betker, analyst.
Applicant/administrator participated in COMP II at CAB via telephone call with analyst at CAB. Identification of the applicant and administrator was verified by confirming driver’s license number. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and 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. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Jude De La Concepcion
LICENSING EVALUATOR NAME: Shannon Betker
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2023
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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