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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850503
Report Date: 07/17/2024
Date Signed: 07/18/2024 07:13:33 AM

Document Has Been Signed on 07/18/2024 07:13 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:BILLION AGE INCFACILITY NUMBER:
195850503
ADMINISTRATOR/
DIRECTOR:		HAKOBYAN, ANNAFACILITY TYPE:
735
ADDRESS:6530 GLORIA AVETELEPHONE:
(361) 222-2223
CITY:LAKE BALBOASTATE: CAZIP CODE:
91406
CAPACITY: 4CENSUS: DATE:
07/17/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:ANNA HAKOBYANTIME VISIT/
INSPECTION COMPLETED:
10:18 AM
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Facility Type: Adult Residential Facility
Application Type: Initial
Capacity: 4
Census (if any clients in care): 0
COMP II Participants: ANNA HAKOBYAN
Interview Method: Telephone interview

On July 17, 2024, 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. Restricted/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
Pre-licensing readiness
SUPERVISORS NAME: Jude De La Concepcion
LICENSING EVALUATOR NAME: Bethany Hunter
LICENSING EVALUATOR SIGNATURE: DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2024
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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