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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530078
Report Date: 12/22/2022
Date Signed: 12/22/2022 09:47:53 AM


Document Has Been Signed on 12/22/2022 09:47 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
, CA 95814



FACILITY NAME:RESSA RESIDENTIAL CAREFACILITY NUMBER:
335530078
ADMINISTRATOR:ANGELES, ARIELFACILITY TYPE:
740
ADDRESS:30002 NORTH LAKE DRTELEPHONE:
(951) 674-4572
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY:6CENSUS: DATE:
12/22/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Angeles, ArielTIME COMPLETED:
09:30 AM
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Facility Type: RCFE
Application Type: CHOW
Capacity: 6
Census (if any clients in care): 2
Interview Method: Telephone interview

On 12/22/2022, applicant/administrator participated in COMP II. Identification of the applicant/ administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant /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
SUPERVISOR'S NAME: Tracy ThompsonTELEPHONE: (916) 657-2025
LICENSING EVALUATOR NAME: Nicole RouseTELEPHONE: (916) 651-7904
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2022
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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