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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002921
Report Date: 08/22/2022
Date Signed: 08/22/2022 02:28:34 PM


Document Has Been Signed on 08/22/2022 02:28 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:GRANNY'S COTTAGE LLCFACILITY NUMBER:
345002921
ADMINISTRATOR:BANCU, ADALBERTHFACILITY TYPE:
740
ADDRESS:7717 DEANTON CT.TELEPHONE:
(916) 606-9670
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 4DATE:
08/22/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Adalberth Bancu, Administrator/LicenseeTIME COMPLETED:
02:20 PM
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Component II completion: Successful

Facility Type: Residential Care Facility for Elderly (RCFE)
Application Type: Change in Ownership (CHOW)
Capacity: 6
Census (if any clients in care): 4
COMP II Participants: Adalberth Bancu, Administrator/Licensee
Interview Method: Telephone interview

On August 22, 2022 at 1:00 PM, Licensee/Administrator participated in COMP II. Identification of the Licensee/Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Licensee/Administrator confirmed the understanding of the California Code Title 22 Regulations.

During COMP II, CAB Analyst confirmed Licensee/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/Licensee. Report sent via email pdf with pre-licensing check list and informed to return signed LIC 809 to CAB by close of business today.
SUPERVISOR'S NAME: Darla NeeleyTELEPHONE: (916) 651-7817
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: 916-657-2469
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2022
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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