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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604579
Report Date: 06/13/2022
Date Signed: 06/15/2022 08:56:24 AM

Document Has Been Signed on 06/15/2022 08:56 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:HEALING ADULT GROUP CARE INC.FACILITY NUMBER:
374604579
ADMINISTRATOR:SAIF, SALLYFACILITY TYPE:
735
ADDRESS:3919 EL CANTO DR.TELEPHONE:
(248) 307-6966
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 6CENSUS: 0DATE:
06/13/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Sally Saif, AdministratorTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA), Tiffany Holmes conducted an announced Pre-Licensing visit to observe the facility's compliance with Title 22, Division 6 regulations and the California health and code. LPA met with Administrator, Sally Saif, Administrator. Facility is applying to serve six (6) clients 18-59 years of age. (4) rooms at the facility and (3) bathrooms.

During today's visit LPA, accompanied by Sally Saif, Administrator conducted a facility tour. LPA observed resident rooms and found them to have proper furnishings, and adequate linens. Sinks accessible to residents had running water. Facility temperature read at 72 degrees Fahrenheit. Facility had a working fire extinguisher. Smoke and carbon monoxide alarms were observed and operational. The Fire Department granted clearance on 04/26/2022. Administrator stated that there will be no weapons or ammunition kept on the facility property. Staff and resident records will be stored in a locked cabinet downstairs. There is a shaded outdoor space and appropriate resident activities. All cleaning supplies or potentially hazardous materials were locked. Facility has a locked area for resident medications and first aid kits. Administrator Certificate expires on 05/19/2023. Component III was reviewed with the Administrator. The application will be sent to the Centralized Application Bureau for final review and approval.

An exit interview was conducted with Sally Saif, Administrator. A copy of this report and Licensee Appeal Rights (LIC 9058 01/16) was provided.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2022
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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