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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006374
Report Date: 11/09/2023
Date Signed: 11/15/2023 09:16:15 AM

Document Has Been Signed on 11/15/2023 09:16 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:SEIFERT HOMES INC - NORDICAFACILITY NUMBER:
306006374
ADMINISTRATOR:SEIFERT, DEBORAHFACILITY TYPE:
735
ADDRESS:873 S NORDICA STTELEPHONE:
(714) 914-7899
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY: 6CENSUS: 6DATE:
11/09/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Licensee/Administrator, Deborah SeifertTIME COMPLETED:
02:00 PM
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Facility Type: ARF
Application Type: CHOW
Capacity: 6
Census (if any clients in care): 6
COMP II Participants: Deborah Seifert, Licensee/Administrator
Interview Method: Telephone interview


On 11/9/2023, applicant/administrator participated in COMP II for the below pending facilities: Seifert Homes Inc - Imperial, 306006370 and Seifert Homes Inc Nordica, 306006374. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant(s) 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: Darla Neeley
LICENSING EVALUATOR NAME: Biridiana Cisneros
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2023
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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