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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006196
Report Date: 01/03/2023
Date Signed: 01/03/2023 11:40:46 AM

Document Has Been Signed on 01/03/2023 11:40 AM - 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:GREENTREE GUEST HOMEFACILITY NUMBER:
306006196
ADMINISTRATOR:GARCIA, ANNA CFACILITY TYPE:
735
ADDRESS:12651 GREENTREE AVENUETELEPHONE:
(657) 251-0444
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY: 4CENSUS: 4DATE:
01/03/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ronald Garcia CEO; Anna C. Garcia AdministratorTIME COMPLETED:
11:30 AM
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Facility Type: ARF
Application Type: CHOW
Capacity: 4
Census (if any clients in care): 4
COMP II Participants: Ronald Garcia CEO; Anna C. Garcia Administrator
Interview Method: Telephone interview

On Dec 30, 2022, applicant/administrator participated in COMP II for the below pending facilities: GREENTREE GUEST HOME/306006196; MORRIE RESIDENTIAL/306006197. 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. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Tracy Thompson
LICENSING EVALUATOR NAME: Ricmar Soriano
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2022
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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