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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804098
Report Date: 01/11/2023
Date Signed: 01/11/2023 10:35:47 AM

Document Has Been Signed on 01/11/2023 10:35 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:INFINITI CARE HOME #3FACILITY NUMBER:
486804098
ADMINISTRATOR:DEVERA, ALEHAFACILITY TYPE:
735
ADDRESS:353 ARLINGTON CIRCLETELEPHONE:
(707) 673-2078
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: DATE:
01/11/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Julie Martuscello-LicenseeTIME COMPLETED:
10:22 AM
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Facility Type: ARF
Application Type: Initial
Capacity: 4
COMP II Participant: Julie Martuscello, Licensee
Interview Method: Telephone interview

On 1/11/23, applicant participated in COMP II. Identification of the applicant was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant 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'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
SUPERVISORS NAME: Mirella Quaranta
LICENSING EVALUATOR NAME: Anna Barrios
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2023
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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