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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320286
Report Date: 03/18/2022
Date Signed: 03/22/2022 10:57:39 AM

Document Has Been Signed on 03/22/2022 10:57 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:ACOSTA FAMILY HOME IFACILITY NUMBER:
198320286
ADMINISTRATOR:ACOSTA, ASHLEYFACILITY TYPE:
735
ADDRESS:1540 EAST CYRENE DRIVETELEPHONE:
(310) 604-8740
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 4CENSUS: 3DATE:
03/18/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ashley Acosta, AdministratorTIME COMPLETED:
10:00 AM
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Component II completion: Successful

Facility Type: Adult Residential Care Facility (ARF)
Application Type: Change in ownership (CHOW)
Capacity: 4
Census (if any clients in care): 3
COMP II Participants: Ashley Acosta, Administrator
Interview Method: Telephone interview

On March 18, 2022, at 9:00 AM. Administrator participated in COMP II. Identification of the Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Administrator confirmed the understanding of the California Code Title 22 Regulations.

During COMP II, CAB Analyst confirmed 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 Administrator. Administrator will return sign copy of report by end of business today. Report email PDF to the Administrator. ****Amended****
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2022
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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