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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603631
Report Date: 01/27/2023
Date Signed: 01/27/2023 02:39:03 PM


Document Has Been Signed on 01/27/2023 02:39 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:ST. SEBASTIAN'S HOME FOR THE ELDERLYFACILITY NUMBER:
198603631
ADMINISTRATOR:MCGEE, BRIANAFACILITY TYPE:
740
ADDRESS:3203 E CAMERON AVETELEPHONE:
(626) 222-2641
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY:6CENSUS: 4DATE:
01/27/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Isaac Reed CEO; Briana McGee AdministratorTIME COMPLETED:
02:29 PM
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Component II completion: Successful
Facility Type: RCFE
Application Type:CHOW
Capacity: 6
Census (if any clients in care): 4

COMP II Participants: Isaac Reed CEO/Briana McGee Administrator
Interview Method: Telephone interview

On January 27, 2023, 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 that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo IDs have been obtained.

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: Tracy ThompsonTELEPHONE: (916) 657-2025
LICENSING EVALUATOR NAME: Ricmar SorianoTELEPHONE: (916) 617-7083
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2023
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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