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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006320
Report Date: 09/11/2023
Date Signed: 09/11/2023 11:04:50 AM

Document Has Been Signed on 09/11/2023 11:04 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:MIRADA MANOR/GREENLEAFFACILITY NUMBER:
306006320
ADMINISTRATOR:JOSE, JOSEPHFACILITY TYPE:
735
ADDRESS:8616 GREENLEAF STREETTELEPHONE:
(818) 274-1809
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: DATE:
09/11/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Joseph Jose & Precious BrownTIME COMPLETED:
10:30 AM
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Component II completion: Successful
Facility Type: ARF
Application Type: CHOW
Capacity: 6
Census (if any clients in care): adults
COMP II Participants: Joseph Jose, licensee & Precious Brown, administrator
Interview Method: Telephone interview

On September 11, 2023, 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. General Provisions, pre-licensing readiness, fire drills, medications, activities, transportation etc.
SUPERVISORS NAME: Julia Kim
LICENSING EVALUATOR NAME: Dianne Ramos
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2023
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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