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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006591
Report Date: 01/07/2025
Date Signed: 01/07/2025 02:27:37 PM

Document Has Been Signed on 01/07/2025 02:27 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:KATELLA SENIOR LIVING COMMUNITYFACILITY NUMBER:
306006591
ADMINISTRATOR/
DIRECTOR:		PERALEZ, JONFACILITY TYPE:
740
ADDRESS:3952 KATELLA AVETELEPHONE:
(562) 596-2773
CITY:LOS ALAMITOSSTATE: CAZIP CODE:
90720
CAPACITY: 140CENSUS: DATE:
01/07/2025
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Peralez, Jon; Burnam, Soon & Looper, WilliamTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
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Facility Type: RCFE
Application Type: CHOW
Capacity:140
Census (if any clients in care): 53
Interview Method: Virtual interview (Go To Meeting)


On 1/7/2025, applicants/administrator participated in COMP II. Identification of the applicants and administrator was verified based on photo ID and other identifying personal information. During COMP II, applicants 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: Julia Kim
LICENSING EVALUATOR NAME: Nicole Rouse
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
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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