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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603613
Report Date: 11/23/2022
Date Signed: 11/23/2022 09:23:24 AM

Document Has Been Signed on 11/23/2022 09:23 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:STAR VIEW RANCHO LOS AMIGOS CRTFACILITY NUMBER:
198603613
ADMINISTRATOR:LOZANO, AIDA YVONNEFACILITY TYPE:
772
ADDRESS:7755 LEEDS STREETTELEPHONE:
(562) 719-2867
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY: 16CENSUS: DATE:
11/23/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lozano, Aida YvonneTIME COMPLETED:
09:15 AM
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Facility Type: SRF
Application Type: Initial
Capacity: 16
Method: Telephone call with CAB

Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. Identification of the applicant/administrator was verified by correctly answering identity verification questions. During COMP II, applicant/administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant/ administrator has been advised to transmit signed LIC 809 with copy of photo ID to CAB.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Staff qualifications and responsibilities
3. Applicant and Administrator qualifications
4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions
5. Grievances, Complaints, Community resources
6. Physical plant, food service
7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of property
SUPERVISORS NAME: Julia Kim
LICENSING EVALUATOR NAME: Nicole Rouse
LICENSING EVALUATOR SIGNATURE: DATE: 11/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/23/2022
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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