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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603733
Report Date: 05/31/2024
Date Signed: 05/31/2024 04:00:08 PM

Document Has Been Signed on 05/31/2024 04:00 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:GRACE PINEDA'S HOME INCFACILITY NUMBER:
198603733
ADMINISTRATOR/
DIRECTOR:		ULLOA, SILVIAFACILITY TYPE:
735
ADDRESS:347 EAST GREENHAVEN STTELEPHONE:
(626) 967-2961
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY: 4CENSUS: DATE:
05/31/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Silva UlloaTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Facility Type: ARF
Application Type: CHOFT (Small Family Home 197806849)
Capacity: 4
Census (if any clients in care): 2
COMP II Participants: Silvia Ulloa
Interview Method: Telephone interview

On May 31, 2024, 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.
During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program

2. Staffing, medications, day program, transportation

3.General Provisions

4. Pre-Licensing readiness

SUPERVISORS NAME: Julia Kim
LICENSING EVALUATOR NAME: Dianne Ramos
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2024
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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