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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006408
Report Date: 01/11/2024
Date Signed: 01/11/2024 02:53:21 PM

Document Has Been Signed on 01/11/2024 02:53 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:HAVEN OF HOPE CARE HOME LLCFACILITY NUMBER:
306006408
ADMINISTRATOR:DACAYO, ROSARIO RFACILITY TYPE:
735
ADDRESS:5040 SOMERSET STTELEPHONE:
(714) 300-9287
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY: 4CENSUS: DATE:
01/11/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Rosario Dacayo / Imelda SamonteTIME COMPLETED:
02:30 PM
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Facility Type: ARF
Application Type: Initial
Capacity: 4
Census (if any clients in care):
COMP II Participants: Rosario Dacayo (Corp/Admin), Imelda Samonte (corp member)
Interview Method: Telephone interview

On January 11, 2024, 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.
SUPERVISORS NAME: Julia Kim
LICENSING EVALUATOR NAME: Dianne Ramos
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2024
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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