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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610355
Report Date: 01/10/2023
Date Signed: 01/11/2023 02:14:49 PM


Document Has Been Signed on 01/11/2023 02:14 PM - 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:B AND B SENIOR IIFACILITY NUMBER:
197610355
ADMINISTRATOR:BAINGAN, GLADELYN P.FACILITY TYPE:
740
ADDRESS:22755 FESTIVIDAD DRIVETELEPHONE:
(661) 600-2838
CITY:SANTA CLARITASTATE: CAZIP CODE:
91354
CAPACITY:6CENSUS: 0DATE:
01/10/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Gladelyn P. Baingan, Licensee/AdministratorTIME COMPLETED:
11:10 AM
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Component II completion: Successful

Facility Type: Residential Care Facility for Elderly (RCFE)
Application Type: Initial
Capacity: 6
Census (if any clients in care): none
COMP II Participants: Gladelyn P. Baingan, Licensee/Administrator
Interview Method: Telephone interview


On January 10, 2023 at 10:00 AM, Licensee/Administrator participated in COMP II. Identification of the Licensee/Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Licensee/Administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22.

During COMP II, CAB Analyst confirmed Licensee/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 conducted with Licensee/Administrator. Report sent via email pdf and request to be return back to CAB by end of business day.
SUPERVISOR'S NAME: Darla NeeleyTELEPHONE: (916) 651-7817
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: 916-657-2469
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2023
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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