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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603457
Report Date: 05/10/2021
Date Signed: 05/10/2021 01:20:41 PM

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 8-3-91
SACRAMENTO, CA 95814
FACILITY NAME:AYANNA HOME CAREFACILITY NUMBER:
198603457
ADMINISTRATOR:MATE, KELVINFACILITY TYPE:
740
ADDRESS:5602 WHITEWOOD AVETELEPHONE:
(909) 351-6012
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY:6CENSUS: DATE:
05/10/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Kelvin Mate, Paul Costa, Jason DyTIME COMPLETED:
11:30 AM
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Facility Type: RCFE, Application Type:CHOW, Capacity: 6 Census (if any clients in care): 3, COMP II Participants: Kelvin Mate (Administrator and Corporate Board Member), Paul Costa (Corporate Board Member), Jason Dy (Consultant)
Interview Method: Telephone interview
On 5/10/21, 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. Applicant/administrator has also been provided with a copy of PIN-20-48-ASC.
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: Julia KimTELEPHONE: (916) 430-2437
LICENSING EVALUATOR NAME: Bailey HumesTELEPHONE: (916) 657-2600
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021
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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