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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850375
Report Date: 08/14/2023
Date Signed: 10/09/2023 01:15:23 PM


Document Has Been Signed on 10/09/2023 01:15 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:PACIFIC HEIGHTS RESIDENTIAL HOME LLCFACILITY NUMBER:
405850375
ADMINISTRATOR:CRADDUCK, CHERLYNFACILITY TYPE:
740
ADDRESS:781 LILAC DRIVETELEPHONE:
(805) 534-1589
CITY:LOS OSOSSTATE: CAZIP CODE:
93402
CAPACITY:5CENSUS: DATE:
08/14/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:CHERLYN CRADDUCKTIME COMPLETED:
11:30 AM
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Facility Type: RCFE
Application Type: CHOW
Capacity: 5
Census (if any clients in care):
COMP II Participants: CHERLYN CRADDUCK
Interview Method: Telephone interview

On 8/14/23, applicant/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. 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
SUPERVISOR'S NAME: Mirella QuarantaTELEPHONE: (916) 657-2025
LICENSING EVALUATOR NAME: Stefania FontenoTELEPHONE: (916) 657-2335
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2023
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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