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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610237
Report Date: 01/18/2022
Date Signed: 01/18/2022 11:20:51 AM

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:ABAD CARE HOMESFACILITY NUMBER:
197610237
ADMINISTRATOR:OLIVAS, MYLINEFACILITY TYPE:
740
ADDRESS:20128 DEVONSHIRE STTELEPHONE:
(747) 237-0417
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:6CENSUS: 5DATE:
01/18/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Myline Olivas, Administrator/LicenseeTIME COMPLETED:
10:10 AM
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Component II completion: Successful

Facility Type: Residential Care Facility for Elderly (RCFE)
Application Type: Change in Ownership (CHOW)
Capacity: 6
Census (if any clients in care): 5
COMP II Participants: Myline Olivas, Administrator/Licensee
Interview Method: Telephone interview


On January 18, 2022 at 9:00 AM, Administrator/Licensee participated in COMP II. Identification of the Administrator/Licensee was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Administrator/Licensee confirmed the understanding of the California Code Title 22 Regulations.

During COMP II, CAB analyst confirmed Administrator/Licensee’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 conducted with Administrator/Licensee. Report sent via PDF email and Administrator/Licensee will return signed copy.
SUPERVISOR'S NAME: Darla NeeleyTELEPHONE: (916) 651-7817
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: 916-657-2469
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022
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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