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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610295
Report Date: 07/13/2022
Date Signed: 07/13/2022 11:33:09 AM


Document Has Been Signed on 07/13/2022 11:33 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:1ST CARING TRADITIONSFACILITY NUMBER:
197610295
ADMINISTRATOR:MEDEL, REYFACILITY TYPE:
740
ADDRESS:3234 TOURNAMENT DRIVETELEPHONE:
(661) 441-0023
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:6CENSUS: 0DATE:
07/13/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Rey Medel, Administrator/Licensee
Amy Morales, Licensee		TIME COMPLETED:
11:30 AM
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Component II completion: Successful

Facility Type: Residential Care Facility for the Elderly (RCFE)
Application Type: Initial
Capacity: 6
Census (if any clients in care): none
COMP II Participants: Rey Medel, Administrator/Licensee
Amy Morales, Licensee
Interview Method: Telephone interview

On July 13, 2022 at 10:35 AM, Licensee and Administrator participated in COMP II. Identification of the Licensee and Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Licensee 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 Ooperation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing Requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General Rrovisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing Readiness

Exit interview conducted with Licensee and Administrator. A copy of report sent to Administrator to sign and return by end of business day to CAB.
SUPERVISOR'S NAME: Darla NeeleyTELEPHONE: (916) 651-7817
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: 916-657-2469
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2022
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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