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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603632
Report Date: 01/27/2023
Date Signed: 07/14/2023 01:20:37 PM


Document Has Been Signed on 07/14/2023 01:20 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
CENTRALIZED APP UNIT, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:ST. SEBASTIAN'S HOME FOR THE ELDERLY IIIFACILITY NUMBER:
198603632
ADMINISTRATOR:MCGEE, BRIANAFACILITY TYPE:
740
ADDRESS:837 N. SUNFLOWER AVENUETELEPHONE:
(626) 222-2641
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY:6CENSUS: DATE:
01/27/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:19 PM
MET WITH: Isaac Reed/Briana McGeeTIME COMPLETED:
01:20 PM
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Component II completion: Successful
Facility Type: RCFE
Application Type:CHOW
Capacity: 6

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: Darla NeeleyTELEPHONE: (916) -65-7817
LICENSING EVALUATOR NAME: Gina BaldwinTELEPHONE: (916) 651-7817
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2023
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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