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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530268
Report Date: 01/06/2025
Date Signed: 01/06/2025 12:08:42 PM

Document Has Been Signed on 01/06/2025 12:08 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
, CA 95814
FACILITY NAME:SALVATION RESIDENTIAL CAREFACILITY NUMBER:
335530268
ADMINISTRATOR/
DIRECTOR:		CAGE, WANDAFACILITY TYPE:
735
ADDRESS:22776 SALVATION WAYTELEPHONE:
(323) 535-8303
CITY:WILDOMARSTATE: CAZIP CODE:
92595
CAPACITY: 6CENSUS: DATE:
01/06/2025
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH: Wanda Cage & Philiet SpaineTIME VISIT/
INSPECTION COMPLETED:
11:40 AM
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Facility Type: ARF
Application Type: Initial
Capacity: 6
Census (if any clients in care): none
COMP II Participants: Wanda Cage & Philiet Spaine
Interview Method: Telephone interview

On January 6, 2025, 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 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.Activities/Medications
3.Staffing Training
4.Pre Licensing Readiness
5.General provisions
SUPERVISORS NAME: Jude De La Concepcion
LICENSING EVALUATOR NAME: Dianne Ramos
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2025
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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