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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604580
Report Date: 10/14/2022
Date Signed: 10/14/2022 10:55:52 AM

Document Has Been Signed on 10/14/2022 10:55 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
SACRAMENTO, CA 95814
FACILITY NAME:NATURE'S RESIDENCEFACILITY NUMBER:
374604580
ADMINISTRATOR:ANDRADE, VICTOR JOSE RFACILITY TYPE:
735
ADDRESS:8554 S SLOPE DRIVETELEPHONE:
(619) 947-4870
CITY:SANTEESTATE: CAZIP CODE:
92071
CAPACITY: 3CENSUS: 0DATE:
10/14/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Victor Andrade, Licensee/AdministratorTIME COMPLETED:
10:50 AM
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Component II completion: Successful

Facility Type: Adult Residential Facility (ARF)
Application Type: Initial
Capacity: 3
Census (if any clients in care): none
COMP II Participants: Victor Andrade, Licensee/Administrator
Interview Method: Telephone interview

On October 14, 2022 at 10:10 AM, Applicant/Administrator participated in COMP II. Identification of the Applicant/Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Applicant/Administrator confirmed the understanding of the California Code Title 22 Regulations.

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/CPMB associations & Training
4. Restrictive/Prohibited Health Conditions
5. General Provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing Readiness

Exit interview conducted with Applicant/Administrator and report sent via email pdf. Informed Applicant/Administrator to return sign copy by end of business today.
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2022
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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