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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603580
Report Date: 09/28/2022
Date Signed: 09/28/2022 02:35:48 PM


Document Has Been Signed on 09/28/2022 02:35 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:BEVERLY HILLS SENIOR CAREFACILITY NUMBER:
198603580
ADMINISTRATOR:DUFRENNE, PATRIAFACILITY TYPE:
740
ADDRESS:1015 S. ORANGE GROVE AVETELEPHONE:
(323) 933-8271
CITY:LOS ANGELESSTATE: CAZIP CODE:
90019
CAPACITY:45CENSUS: 43DATE:
09/28/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Patria Dufrenne, Administrator/Applicant
Jennifer Rivas, Co-Administrator		TIME COMPLETED:
02:00 PM
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Component II completion: Successful

Facility Type: Residential Care Facility for Elderly (RCFE)
Application Type: Change in Ownership (CHOW)
Capacity: 45
Census (if any clients in care): 43
COMP II Participants: Patria Dufrenne, Administrator
Jennifer Rivas, Co-Administrator
Interview Method: Telephone interview

On September 28, 2022, Applicant and 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.

During COMP II, CAB Analyst confirmed Applicant and Administrator’s understanding of following areas:
1. Facility Operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing Requirements/CPMB associations & Training
4. Restrictive/Prohibited Health Conditions
5. General Provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing Readiness

Exit interview conducted with Applicant and Administrator. Copy of report sent via email PDF and informed to signed and return by end of close of business day today.
SUPERVISOR'S NAME: Darla NeeleyTELEPHONE: (916) 651-7817
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: 916-657-2469
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2022
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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