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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881184
Report Date: 09/28/2021
Date Signed: 09/28/2021 12:06:34 PM

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:VIPHEALTH SERVICES, LLCFACILITY NUMBER:
331881184
ADMINISTRATOR:SASIS, PRINCE NORRISFACILITY TYPE:
740
ADDRESS:1167 SHADY CREEK DRTELEPHONE:
(909) 225-3462
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92407
CAPACITY:6CENSUS: DATE:
09/28/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:18 AM
MET WITH:Prince SasisTIME COMPLETED:
11:30 AM
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Component II completion: Successful
Facility Type: RCFE Application Type: INITL Capacity: 6 COMP II Participants: Sasis, Prince (Board member, Administrator) Interview Method: Telephone interview
On 9/28/2021, 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 the understanding of the California Code Title 22 Regulations. 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
SUPERVISOR'S NAME: Julia KimTELEPHONE: (916) 430-2437
LICENSING EVALUATOR NAME: Bailey HumesTELEPHONE: (916) 657-2600
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
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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