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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006313
Report Date: 07/18/2023
Date Signed: 07/19/2023 08:31:48 AM


Document Has Been Signed on 07/19/2023 08:31 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:FOUNTAIN OF YOUTH SENIOR LIVINGFACILITY NUMBER:
306006313
ADMINISTRATOR:JERRAR, MOE A.FACILITY TYPE:
740
ADDRESS:525 N CAROUSEL PLACETELEPHONE:
(657) 208-3199
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY:6CENSUS: 4DATE:
07/18/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Moe Jerrar, Applicant/AdministatorTIME COMPLETED:
11:25 AM
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Component II completion: Successful

Facility Type: Residential Care Facility for Elderly (RCFE)
Application Type: Change in Ownership (CHOW)
Capacity: 6
Census (if any clients in care): 4
COMP II Participants: Moe Jerrar, Applicant/Administrator
Interview Method: Telephone interview

On July 18, 2023, Applicant/Administrator participated in COMP II. Identification of the Applicant/Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Applicant/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.

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

Exit interview conducted with Applicant/Administrator. Copy of report sent via email pdf and request to return sign copy to CAB by end of business day.
***Name correction for signature below****
SUPERVISOR'S NAME: Darla NeeleyTELEPHONE: (916) 651-7817
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023
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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