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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002830
Report Date: 12/07/2021
Date Signed: 12/07/2021 02:31:45 PM

Document Has Been Signed on 12/07/2021 02:31 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:REM CALIFORNIA, LLC - SAN JUANFACILITY NUMBER:
345002830
ADMINISTRATOR:HENRY, STEPHANIEFACILITY TYPE:
735
ADDRESS:3831 SAN JUAN AVENUETELEPHONE:
(916) 550-0668
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 4CENSUS: DATE:
12/07/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Stephanie Henry-AdministratorTIME COMPLETED:
01:11 PM
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Facility Type: ARF
Application Type: CHOW
Capacity: 4
Census: 4
COMP II Participant: Stephanie Henry, Administrator
Interview Method: Telephone interview

On 12/7/21, administrator participated in COMP II. Identification of the administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, 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 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
SUPERVISORS NAME: Mirella Quaranta
LICENSING EVALUATOR NAME: Anna Barrios
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2021
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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