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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604722
Report Date: 09/15/2023
Date Signed: 09/15/2023 02:14:25 PM


Document Has Been Signed on 09/15/2023 02:14 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
SACRAMENTO, CA 95814



FACILITY NAME:NOVELLUS CLAIREMONT LLCFACILITY NUMBER:
374604722
ADMINISTRATOR:LAIRD, CANDIFACILITY TYPE:
740
ADDRESS:5219 CLAIREMONT MESA BLVD.TELEPHONE:
(858) 292-8044
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY:214CENSUS: 79DATE:
09/15/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:06 PM
MET WITH:Candi Laird, Administrator
Larry John, Applicant		TIME COMPLETED:
02:07 PM
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Component II completion: Successful

Facility Type: Residential Care Facility for the Elderly (RCFE)
Application Type: Change in Ownership (CHOW)
Capacity: 214
Census (if any clients in care): 79
COMP II Participants: Candi Laird, Administrator
Larry John, Applicant
Interview Method: Telephone interview

On September 15, 2023, Applicant and 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 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.

During COMP II, CAB Analyst confirmed Applicant and 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

Exit interview conducted with Administrator and Applicant. Report sent via pdf email and informed to return sign copy to CAB by end of business day today.
SUPERVISOR'S NAME: Darla NeeleyTELEPHONE: (916) 651-7817
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: 916-657-2469
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2023
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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