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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006370
Report Date: 11/09/2023
Date Signed: 11/09/2023 01:59:15 PM

Document Has Been Signed on 11/09/2023 01:59 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:SEIFERT HOMES INC. - IMPERIALFACILITY NUMBER:
306006370
ADMINISTRATOR:SEIFERT, DEBORAHFACILITY TYPE:
735
ADDRESS:9292 IMPERIAL AVE.TELEPHONE:
(714) 741-4933
CITY:GARDEN GROVESTATE: CAZIP CODE:
92844
CAPACITY: 6CENSUS: 6DATE:
11/09/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Deborah Seifert, Applicant/AdministratorTIME COMPLETED:
02:00 PM
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Component II completion: Successful

Facility Type: Adult Residential Facility (ARF)
Application Type: Change in Ownership (CHOW)
Capacity: 6
Census (if any clients in care): 6
COMP II Participants: Deborah Seifert, Applicant/Administrator
Interview Method: Telephone interview

On November 9, 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. S

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 and informed to return sign copy by end of business today.
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2023
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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