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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610232
Report Date: 01/11/2022
Date Signed: 01/11/2022 11:40:16 AM

Document Has Been Signed on 01/11/2022 11:40 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:360 CARE, INC.FACILITY NUMBER:
197610232
ADMINISTRATOR:MCKAY III, GEORGEFACILITY TYPE:
735
ADDRESS:45328 ROBINSON DRTELEPHONE:
(818) 201-5250
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 0DATE:
01/11/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:George McKay III, Administrator/Licensee
Rhonda (Teruneh) McKay, Licensee		TIME COMPLETED:
11:35 AM
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Component II completion: Successful

Facility Type: Adult Residential Facility (ARF)
Application Type: Initial
Capacity: 4 (all-ambulatory_
Census (if any clients in care): 0
COMP II Participants: George McKay III, Administrator/Licensee
Rhonda (Teruneh) McKay, Licensee
Interview Method: Telephone interview

On January 11, 2022 at 10:30 AM, Applicants and Administrator participated in COMP II. Identification of the Applicants 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.

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

Exit interview conduct with Applicants and Administrator. Analyst send hard copy via PDF email and will obtained signed copy.
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2022
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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