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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530265
Report Date: 01/09/2025
Date Signed: 02/04/2025 03:14:19 PM

Document Has Been Signed on 02/04/2025 03:14 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:CONEJO CARE HOMEFACILITY NUMBER:
365530265
ADMINISTRATOR/
DIRECTOR:		SESAY, ABIJATUFACILITY TYPE:
735
ADDRESS:2459 CONEJO DRTELEPHONE:
(424) 702-2078
CITY:SAN BERNADINOSTATE: CAZIP CODE:
92404
CAPACITY: 4CENSUS: DATE:
01/09/2025
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Sasay, AbijatuTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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COMP II by CAB successfully completed

Method: Phone Call at CAB

Applicant/administrator participated in COMP II at CAB telephone call with analyst at CAB. Identification of the applicant and administrator was verified by presenting photo ID via phone. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:

1. Facility operation: License type, client/resident populations, and program

2. Staff qualifications and responsibilities

3. Applicant and Administrator qualifications

4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions

5. Grievances, Complaints, Community resources

6. Physical plant, food service

7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of property

SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Gina Baldwin
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2025
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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