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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604641
Report Date: 11/02/2023
Date Signed: 11/02/2023 02:36:09 PM


Document Has Been Signed on 11/02/2023 02:36 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
SACRAMENTO, CA 95814



FACILITY NAME:POWAY GARDENS SENIOR LIVING - SYCAMORESFACILITY NUMBER:
374604641
ADMINISTRATOR:WILLIAMS, DONELLEFACILITY TYPE:
740
ADDRESS:12738 MONTE VISTA ROADTELEPHONE:
(658) 674-1255
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:6CENSUS: DATE:
11/02/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Donelle Williams, AdministratorTIME COMPLETED:
03:00 PM
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Component II completion: Successful

Facility Type: Residential Care Facility for Elderly (RCFE)
Application Type: Change in Ownership (CHOW)
Capacity: 6
Census (if any clients in care): unknown.
COMP II Participants: Donelle Williams, Administrator
Interview Method: Waived

On August 22, 2023, applicant(s)/administrator participated in COMP II for the below pending facilities:
  1. Poway Gardens Senior Living - Magnolia #374604648
  2. Poway Gardens Senior Living - The Palms #374604645
  3. Poway Gardens Senior Living - The Pine #374604634

Identification of the applicant(s) and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant(s) 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.

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. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness

COMPONENT II waived.
SUPERVISOR'S NAME: Darla NeeleyTELEPHONE: (916) 651-7817
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: 916-657-2469
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023
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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