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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610430
Report Date: 06/30/2023
Date Signed: 06/30/2023 09:22:25 AM


Document Has Been Signed on 06/30/2023 09:22 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:MONTECEDROFACILITY NUMBER:
197610430
ADMINISTRATOR:WEIDERT, DAVIDFACILITY TYPE:
741
ADDRESS:2212 EL MOLINO AVE.TELEPHONE:
(626) 403-5403
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY:300CENSUS: DATE:
06/30/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:David Weidert, Charles RahillyTIME COMPLETED:
09:20 AM
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Facility Type: Residential Care Facility for the Elderly - Continuing Care Retirement Community
Application Type: Change of Ownership
Capacity: 300
Census (if any clients in care): Unknown
COMP II Participants: David Weidert, Charles Rahilly
Interview Method: Telephone interview
On June 30, 2023, 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
8. Pre-licensing readiness
SUPERVISOR'S NAME: Jude De La ConcepcionTELEPHONE: (916) 651-7841
LICENSING EVALUATOR NAME: Bethany HunterTELEPHONE: (916) 651-3571
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2023
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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