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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530069
Report Date: 01/17/2023
Date Signed: 01/17/2023 10:50:23 AM

Document Has Been Signed on 01/17/2023 10:50 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:GRAPHITE HOME - SALEM CHRISTIAN HOMESFACILITY NUMBER:
365530069
ADMINISTRATOR:DAWSON, SHELLYFACILITY TYPE:
735
ADDRESS:4787 GRAPHITE CREED RD.TELEPHONE:
(909) 614-0575
CITY:JURUPA VALLEYSTATE: CAZIP CODE:
91752
CAPACITY: 4CENSUS: 0DATE:
01/17/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee, Rod Bollins & Administrator, Shelly DawsonTIME COMPLETED:
09:30 AM
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Facility Type: ARF
Application Type: INITIAL
Capacity: 4
Census (if any clients in care): 0
COMP II Participants: Licensee, Rod Bollins & Administrator, Shelly Dawson
Interview Method: Telephone interview

On 1/17/2023, applicant & administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and 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. 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
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Biridiana Cisneros
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2023
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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