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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320228
Report Date: 11/16/2021
Date Signed: 11/16/2021 09:44:48 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:PACIFIC ADULT CAREFACILITY NUMBER:
198320228
ADMINISTRATOR:FERGUSON, AARONFACILITY TYPE:
740
ADDRESS:8755 WEST OLYMPIC BLVDTELEPHONE:
(323) 809-0591
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY:150CENSUS: 0DATE:
11/16/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Aaron FergusonTIME COMPLETED:
09:32 AM
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Facility Type: Residential Care Facility for the Elderly
Application Type: Initial
Capacity: 150
Census (if any clients in care): None
COMP II Participants: Aaron Ferguson
Interview Method: Telephone interview
On November 16, 2021, 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. Restrictive/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: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
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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