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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920179
Report Date: 09/20/2024
Date Signed: 09/20/2024 11:51:39 AM

Document Has Been Signed on 09/20/2024 11:51 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:NEW DEVOTION FAMILY CARE HOME LLCFACILITY NUMBER:
315920179
ADMINISTRATOR/
DIRECTOR:		BLAS, MEKISHAFACILITY TYPE:
735
ADDRESS:572 SILVER CLOUD CT.TELEPHONE:
(863) 205-4134
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 4CENSUS: 0DATE:
09/20/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Shawnette Etheridge, Applicant
Mekisha Blas, Administrator		TIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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Component II completion: Successful

Facility Type: Adult Residential Facility (ARF)
Application Type: Initial
Capacity: 4
Census (if any clients in care): none
COMP II Participants: Shawnette Etheridge, Applicant
Mekisha Blas, Administrator
Interview Method: Telephone interview

On September 20, 2024 at 11:00 AM, Applicant and 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.

During COMP II, CAB analyst confirmed Applicant and 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 and Administrator. Report sent via email and request to return sign copy by end of business day today.
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2024
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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