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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850238
Report Date: 02/16/2022
Date Signed: 02/17/2022 08:54:27 AM

Document Has Been Signed on 02/17/2022 08:54 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:BAGET'S HOMEFACILITY NUMBER:
195850238
ADMINISTRATOR:BAGET, BADUNG DAVOUFACILITY TYPE:
735
ADDRESS:7524 WISH AVETELEPHONE:
(818) 518-4635
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY: 3CENSUS: DATE:
02/16/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH: BADUNG BAGET Applicant/administrator TIME COMPLETED:
02:45 PM
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Facility Type: ARF
Application Type: INTIAL
Capacity: 3 (DD)
Census (if any clients in care): NO

Method: Telephone call with CAB
COMP II Participants: BADUNG BAGET Applicant/administrator
Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1.Facility operation: License type, client/resident populations, and program
2.Staff qualifications and responsibilities
3.Applicant and Administrator qualifications
4.Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions
5.Grievances, Complaints, Community resources
6.Physical plant, food service
7.Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of property

8. Discussed the COVID-19 Mitigation Plan & PIN emailed

SUPERVISORS NAME: Jude De La Concepcion
LICENSING EVALUATOR NAME: Maria Ejaz
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2022
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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