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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850413
Report Date: 05/31/2024
Date Signed: 05/31/2024 10:10:12 AM

Document Has Been Signed on 05/31/2024 10:10 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:GINA SCHWICHTENBERG ARF IIIFACILITY NUMBER:
405850413
ADMINISTRATOR/
DIRECTOR:		SCHWICHTENBERG, GINAFACILITY TYPE:
735
ADDRESS:241 CHEYENNE DRTELEPHONE:
(951) 206-6977
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 4CENSUS: 0DATE:
05/31/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Gina Schwichtenberg, Applicant/AdministratorTIME VISIT/
INSPECTION COMPLETED:
09:57 AM
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Component II completion: Successful

Facility Type: Adult Residential Facility (ARF)
Application Type: Initial
Capacity: 4 all ambulatories
Census (if any clients in care): none
COMP II Participants: Gina Schwichtenberg, Applicant/Administrator
Interview Method: Telephone interview

On May 31, 2024 at 9:00 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 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/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/Applicant. Report sent via email and request to return sign copy by end of business day today.
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2024
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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