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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209408
Report Date: 05/07/2024
Date Signed: 05/07/2024 03:59:44 PM


Document Has Been Signed on 05/07/2024 03:59 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:SEVA CARE HOMEFACILITY NUMBER:
247209408
ADMINISTRATOR:MANN, KHUSHBIRFACILITY TYPE:
740
ADDRESS:1072 DALLAS DRIVETELEPHONE:
(916) 509-0875
CITY:LIVINGSTONSTATE: CAZIP CODE:
95334
CAPACITY:6CENSUS: DATE:
05/07/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Mann, KhushbirTIME COMPLETED:
03:40 PM
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Facility Type: RCFE
Application Type: Initial
Capacity: 6
Census (if any clients in care): none
COMP II Participants: Mann, Khushbir
Interview Method: Telephone interview

On May 7, 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. Pre licensing readiness

3. Staffing requirements & Training

SUPERVISOR'S NAME: Julia KimTELEPHONE: (916) 651-7848
LICENSING EVALUATOR NAME: Dianne RamosTELEPHONE: (916) 653-5973
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024
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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