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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610485
Report Date: 02/01/2024
Date Signed: 02/02/2024 08:21:02 AM

Document Has Been Signed on 02/02/2024 08:21 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:AMEND TREATMENTFACILITY NUMBER:
197610485
ADMINISTRATOR:FLINN, DIANEFACILITY TYPE:
772
ADDRESS:6758 WILDLIFE ROADTELEPHONE:
(805) 912-6363
CITY:MALIBUSTATE: CAZIP CODE:
90265
CAPACITY: 6CENSUS: 5DATE:
02/01/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator, Diane Flinn and Licensees, Steve Roe & Tom Croke TIME COMPLETED:
11:30 AM
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Facility Type: SRF
Application Type: CHOW
Capacity: 6
Census (if any clients in care): 0
COMP II Participants: Dianne Flinn, Administrator ; Steve Roe, Licensee ; Tom Croke, Licensee
Interview Method: MS Teams Meeting

On 2/1/2024, applicant(s)/administrator participated in COMP II for the below pending facilities: Amend Treatment, 197610485, Amend Treatment - Portshead, 197610497. Identification of the applicant(s) and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant(s) and 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. 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. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Biridiana Cisneros
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2024
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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