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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603500
Report Date: 10/14/2021
Date Signed: 10/20/2021 02:12:39 PM

Document Has Been Signed on 10/20/2021 02:12 PM - 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:BHAVATHI LLCFACILITY NUMBER:
198603500
ADMINISTRATOR:REDDY,LAKSHMIFACILITY TYPE:
740
ADDRESS:784 POMELLO DRIVETELEPHONE:
(626) 376-7796
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 6CENSUS: 0DATE:
10/14/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Lakshmi Reddy, AdministratorTIME COMPLETED:
12:10 PM
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COMP II by CAB incomplete.

Facility Type: RCFE
Application Type: Initial
Capacity: 6
Census (if any clients in care): 0
COMP II Participants: Lakshmi Reddy, Administrator
Interview Method: Telephone interview

On October 14, 2021 at 11:0 AM, Administrator participated in COMP II via telephone with Analyst, Celia Phomphachanh. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. Applicant and/or administrator did not provide sufficient knowledge the program and the California Code Title 22 Regulations. Component II will be rescheduled. Signed LIC 809 with copy of photo ID have been obtained.

Interviewed concluded with Administrator. LIC 809 will be sent via email PDF to Administrator.

Reschedule to October 20, 2021.

SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME: BHAVATHI LLC
FACILITY NUMBER: 198603500
VISIT DATE: 10/14/2021
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On October 14, 2021, Thursday, during COMPONENT II interview, Administrator informed Analyst of providing activities such as swimming. Analyst was not aware facility has pool and jacuzzi fenced. Analyst ended the COMPONENT II until Administrator provide updated LIC 999-Facility Sketch to include pool and jacuzzi, in addition to include in Program Description under activities. Analyst concluded COMPONENT II at 12:10 PM until Administrator provided updated documentation.
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
LIC809 (FAS) - (06/04)
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