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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881127
Report Date: 05/05/2021
Date Signed: 05/05/2021 10:48:05 AM

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 8-3-91
SACRAMENTO, CA 95814
FACILITY NAME:HOME CARE FIRSTFACILITY NUMBER:
361881127
ADMINISTRATOR:ESCOBEDO, ADDYFACILITY TYPE:
740
ADDRESS:14186 CUYAMACA RDTELEPHONE:
(323) 350-2415
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY:6CENSUS: DATE:
05/05/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:Addy Escobedo-Administrator/LicenseeTIME COMPLETED:
10:21 AM
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Facility Type: RCFE
Application Type: Initial
Capacity: 6
COMP II Participant: Addy Escobedo, Administrator/Licensee
Interview Method: Telephone interview

On 5/5/21, 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 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 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: Mirella QuarantaTELEPHONE: (916) 657-2025
LICENSING EVALUATOR NAME: Anna BarriosTELEPHONE: (916) 651-7817
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021
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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