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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881559
Report Date: 08/16/2024
Date Signed: 08/16/2024 02:33:01 PM

Document Has Been Signed on 08/16/2024 02:33 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:SOC CAREFACILITY NUMBER:
331881559
ADMINISTRATOR/
DIRECTOR:		CARRAWAY, LAQUITAFACILITY TYPE:
735
ADDRESS:644 FIELD MAPLE PLACETELEPHONE:
(951) 665-3489
CITY:SAN JACINTOSTATE: CAZIP CODE:
92583
CAPACITY: 3CENSUS: 0DATE:
08/16/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:S'halana Carter, ApplicantTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Component II completion: Successful

Facility Type: Adult Residential Facility (ARF)
Application Type: Initial
Capacity: 3
Census (if any clients in care): none
COMP II Participants: S'halana Carter, Applicant
Interview Method: Telephone interview

On August 16, 2024 at 1:00 PM, applicant participated in COMP II. Identification of the applicant was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant 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'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. Report sent via email and informed applicant to return sign copy to CAB by end of business day today.
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2024
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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