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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006047
Report Date: 11/19/2021
Date Signed: 11/19/2021 04:15:49 PM

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:KNOTT'S LANDING LUXURY CAREFACILITY NUMBER:
306006047
ADMINISTRATOR:RAJPOOT, FAISALFACILITY TYPE:
740
ADDRESS:6359 ARNOLD WAYTELEPHONE:
(949) 290-1826
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY:6CENSUS: 0DATE:
11/19/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Faisal Rajpoot, Administrator/Licensee
Kamil Rajpoot, Manager/Licensee
TIME COMPLETED:
02:25 PM
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COMP II by CAB successfully completed.

Facility Type: RCFE
Application Type: Initial
Capacity: 6 all can be non-ambulatory
Census (if any clients in care): 0
COMP II Participants: Faisal Rajpoot, Administrator/Licensee
Kamil Rajpoot, Manager/Licensee

Interview Method: Telephone interview

On November 19, 2021 at 1:00 PM, Administrator and Manager participated in COMP II via telephone with Analyst, Celia Phomphachanh from CAB. Identification of the Licensee was verified by providing California Driver License number verbally. During COMP II, Applicant confirmed the understanding of Title 22 and Health and Safety Codes. Component II was successfully completed. Administrator and Manager were advised to email/fax signed LIC 809 with copy of photo ID to CAB.a

During COMP II, CAB Analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility Operation: License type, client/resident populations, and program
2. Staff Qualifications and responsibilities
3. Applicant and Administrator Qualifications
4. Program Policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions
5. Grievances, Complaints, Community resources
6. Physical Plant and Food Service
7. Application Document Review and Technical Assistance: Criminal Record Clearance, Health Screening, Fire Clearance, First Aid/CPR Certificate, Administrator Certificate, Financial Verification, Pre-licensing Inspection, Compliance History and Control of property.

Interviewed concluded with Administrator and Manager. LIC 809 will be sent via email PDF to Administrator.

SUPERVISOR'S NAME: Darla NeeleyTELEPHONE: (916) 651-7817
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
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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