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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603647
Report Date: 06/29/2023
Date Signed: 10/09/2023 12:37:33 PM

Document Has Been Signed on 10/09/2023 12:37 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:KONICE CARE INCFACILITY NUMBER:
198603647
ADMINISTRATOR:EKAUN, WILSONFACILITY TYPE:
735
ADDRESS:14511 NEARGROVE ROADTELEPHONE:
(562) 273-0434
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 4CENSUS: DATE:
06/29/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:John Wilson / Ifunanya IfeachoTIME COMPLETED:
02:30 PM
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Component II completion: Successful

Facility Type: ARF
Application Type: Initial
Capacity: 4
Census (if any clients in care): none
COMP II Participants: John Wilson Ekaun, admin & Ifunanya Ifeacho, member
Interview Method: Telephone interview

On June 29, 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 ID have been obtained.
SUPERVISORS NAME: Julia Kim
LICENSING EVALUATOR NAME: Dianne Ramos
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2023
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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