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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202907
Report Date: 08/24/2023
Date Signed: 08/24/2023 09:28:48 AM

Document Has Been Signed on 08/24/2023 09:28 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:CALIFORNIA MENTAL HEALTH LLCFACILITY NUMBER:
435202907
ADMINISTRATOR:CISNA, DEREKFACILITY TYPE:
772
ADDRESS:14865 MARIE COURTTELEPHONE:
(949) 836-6793
CITY:SAN MARTINSTATE: CAZIP CODE:
95046
CAPACITY: 8CENSUS: 0DATE:
08/24/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Derek CisnaTIME COMPLETED:
09:30 AM
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Licensing Program Analyst (LPA) Christine Dolores arrived announced to conduct the facility's pre-licensing continuation visit to complete the COMPONENT III due to technical difficulties on 08/22/2023. LPA met with Administrator Derek Cisna.

COMP III was reviewed and completed with the Administrator.

No issues noted during this pre-licensing inspection.

LPA observed the facility is ready to be licensed. However, this report will be submitted to the Central Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

This report was reviewed with Administrator Derek Cisna and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2023
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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