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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006152
Report Date: 05/04/2022
Date Signed: 05/04/2022 02:14:18 PM


Document Has Been Signed on 05/04/2022 02:14 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:COUNTRY GARDENS TERRACE, INC.FACILITY NUMBER:
306006152
ADMINISTRATOR:CATACUTAN, JEANFACILITY TYPE:
740
ADDRESS:1103 SALVADOR STREETTELEPHONE:
(714) 557-0515
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:6CENSUS: DATE:
05/04/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jean Caracutan, Jacqueline DizonTIME COMPLETED:
02:13 PM
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Component II completion: Successful

Facility Type: RCFE
Application Type: CHOW
Capacity: 6
Census (if any clients in care): 5
COMP II Participants: Jean Caracutan, Jacqueline Dizon
Interview Method: Telephone

On 5/4/22, 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 the understanding of the California Code Title 22 Regulations. 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. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness

Cell: 562-522-2002
SUPERVISOR'S NAME: Mirella QuarantaTELEPHONE: (916) 657-2025
LICENSING EVALUATOR NAME: Susan NguyenTELEPHONE: (916) 657-2600
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022
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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