<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700996
Report Date: 04/23/2021
Date Signed: 04/26/2021 09:40:52 AM

Document Has Been Signed on 04/26/2021 09:40 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 8-3-91
SACRAMENTO, CA 95814
FACILITY NAME:WELLQUEST GRANITE BAY TENANTCO LLCFACILITY NUMBER:
312700996
ADMINISTRATOR:MANOMHEHRI, PARIFACILITY TYPE:
740
ADDRESS:9747 SIERRA COLLEGE BLVDTELEPHONE:
(801) 815-0808
CITY:GRANITE BAYSTATE: CAZIP CODE:
95661
CAPACITY: 135CENSUS: DATE:
04/23/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Dean Mattsson and Pari Manomhehri TIME COMPLETED:
10:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
COMP II by CAB successfully completed


Facility Type: RCFE
Application Type: LLC
Capacity: 135
Census (if any clients in care): NO
Method: Telephone at CAB
COMP II Participants: Dean Mattsson (Applicant) and Pari Manomhehri (Administrator)

Applicant/Administrator participated in COMP II at CAB via telephone with analyst at CAB. Identification of the Applicant and Administrator was verified by providing California Driver License number. During COMP II, Applicant and Administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and Administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:

1. Facility operation: License type, client/resident populations, and program


2. Staff qualifications and responsibilities
3. Applicant and Administrator qualifications
4. Program policy: Abuse, admission agreement, medication management, reporting
incidents to CCL, restricted & prohibited conditions
5. Grievances, Complaints, Community resources
6. Physical plant, food service
Application document review and technical assistance: Criminal record clearance,
Health screening, Fire clearance, First Aid/CPR certificate, Administrator
certificate, Financial verification, Pre-licensing inspection, Compliance history,
Control of property
SUPERVISORS NAME: Julia Kim
LICENSING EVALUATOR NAME: Thai Doan
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1