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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530196
Report Date: 02/07/2024
Date Signed: 02/07/2024 12:07:30 PM


Document Has Been Signed on 02/07/2024 12:07 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:TREE OF LIFE CARE HOMEFACILITY NUMBER:
365530196
ADMINISTRATOR:RAJPOOT, BILALFACILITY TYPE:
740
ADDRESS:1652 VIA SEVILLA STTELEPHONE:
(714) 883-3303
CITY:CORONASTATE: CAZIP CODE:
92881
CAPACITY:6CENSUS: DATE:
02/07/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Bilal Rajpoot, Babar MahmudTIME COMPLETED:
10:25 AM
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Facility Type: Residential Care Facility for the Elderly
Application Type: Initial
Capacity: 6
Census (if any clients in care): 0
COMP II Participants: Bilal Rajpoot, Babar Mahmud
Interview Method: Telephone interview

On February 07, 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 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. Restricted/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISOR'S NAME: Joshua MillerTELEPHONE: (916) 651-0571
LICENSING EVALUATOR NAME: Bethany HunterTELEPHONE: (916) 651-7901
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024
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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