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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850151
Report Date: 04/26/2021
Date Signed: 04/26/2021 11:33:21 AM

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 8-3-91
SACRAMENTO, CA 95814
FACILITY NAME:JIREH SENIOR HOMEFACILITY NUMBER:
425850151
ADMINISTRATOR:HERNANDEZ,PATRICIA MONTANOFACILITY TYPE:
740
ADDRESS:2102 CALLE MIRASOLTELEPHONE:
(805) 863-1926
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY:6CENSUS: 0DATE:
04/26/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:03 AM
MET WITH:Patricia HernandezTIME COMPLETED:
11:32 AM
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Facility Type: Residential Care Facility for the Elderly
Application Type: Initial

Applicant/administrator participated in COMP II via call with analyst at CAB. Identification of the applicant and administrator was verified. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB.

During COMP II, CAB analyst confirmed Applicant/administrator’s understanding of following areas:
1.Facility operation: License type, client/resident populations, and program
2.Staff qualifications and responsibilities
3.Applicant and Administrator qualifications
4.Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions
5.Grievances, Complaints, Community resources
6.Physical plant, food service
7.Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of property
SUPERVISOR'S NAME: Jude De La ConcepcionTELEPHONE: (916) 651-7841
LICENSING EVALUATOR NAME: Bethany HunterTELEPHONE: (916) 651-3571
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2021
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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