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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530037
Report Date: 09/14/2022
Date Signed: 09/14/2022 11:01:22 AM

Document Has Been Signed on 09/14/2022 11:01 AM - 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:NEW HAVENFACILITY NUMBER:
365530037
ADMINISTRATOR:JOSE, JOSEPHFACILITY TYPE:
735
ADDRESS:13019 LEAWOOD STREETTELEPHONE:
(818) 274-1809
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 4CENSUS: 4DATE:
09/14/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Oyewole Joseph Jose, AdministratorTIME COMPLETED:
10:50 AM
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Component II completion: Successful

Facility Type: Adult Residential Facility (ARF)
Application Type: Change in Ownership (CHOW)
Capacity: 4
Census (if any clients in care): 4
COMP II Participants: Oyewole Joseph Jose, Administrator
Interview Method: Telephone interview

On September 14, 2022, 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.

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

Exit interview conducted with Administrator. Report email via PDF and informed to return document signed by end of close of business today with pre-licensing checklist.
SUPERVISORS NAME: Joshua Miller
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2022
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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