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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701220
Report Date: 12/08/2022
Date Signed: 12/08/2022 12:10:39 PM

Document Has Been Signed on 12/08/2022 12:10 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:LEGENDARY WAYFACILITY NUMBER:
342701220
ADMINISTRATOR:GREEN, ROBERT J.FACILITY TYPE:
735
ADDRESS:9273 LEGENDARY CT.TELEPHONE:
(916) 248-1991
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 4CENSUS: 0DATE:
12/08/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Robert Green, Adminstrator
Angelina Green, Employee		TIME COMPLETED:
12:00 PM
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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: Robert Green, Administrator/ Angelina Green, employee
Interview Method: Telephone interview

On December 8, 2022 at 11:00 AM , Administrator and employee participated in COMP II. Identification of the Administrator and employee was verified through interview questions based on photo ID and other identifying personal information. During COMP II, 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/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 Administrator. Report sent via email PDF and informed Administrator to return signed copy by end of business today.
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2022
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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