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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530167
Report Date: 01/18/2024
Date Signed: 01/18/2024 03:12:59 PM


Document Has Been Signed on 01/18/2024 03:12 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
, CA 95814



FACILITY NAME:VENUS' COZY COTTAGEFACILITY NUMBER:
365530167
ADMINISTRATOR:RUDER, VENUSFACILITY TYPE:
740
ADDRESS:2955 IRVINGTON AVENUETELEPHONE:
(562) 508-6698
CITY:SAN BERNADINOSTATE: CAZIP CODE:
92407
CAPACITY:6CENSUS: DATE:
01/18/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Venus RuderTIME COMPLETED:
02:40 PM
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Facility Type: RCFE
Application Type: Initial
Capacity:
Census (if any clients in care):
COMP II Participants: Venus Ruder;admin;member
Interview Method: Telephone interview

On January 18, 2024, 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.
SUPERVISOR'S NAME: Jude De La ConcepcionTELEPHONE: (916) 651-7841
LICENSING EVALUATOR NAME: Dianne RamosTELEPHONE: (916) 653-5973
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024
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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