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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804156
Report Date: 07/24/2023
Date Signed: 07/24/2023 11:02:52 AM

Document Has Been Signed on 07/24/2023 11:02 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:PENNGROVE GARDENSFACILITY NUMBER:
496804156
ADMINISTRATOR:CARDENAS, CRISANTEFACILITY TYPE:
740
ADDRESS:1895 ALAN DRIVETELEPHONE:
(707) 327-6968
CITY:PENNGROVESTATE: CAZIP CODE:
94951
CAPACITY: 8CENSUS: 7DATE:
07/24/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Cristane Cardenas, Applicant/Administrator
Lisa Cortez, Applicant		TIME COMPLETED:
11:00 AM
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Component II completion: Successful

Facility Type: Resident Care Facility for the Elderly (RCFE)
Application Type: Change in Ownership (CHOW)
Capacity: 8
Census (if any clients in care): 7
COMP II Participants: Crisante Cardenas, Applicant/Administrator
Lisa Cortez, Applicant
Interview Method: Telephone interview

On July 24, 2023 at 10:00 AM, Applicants and Administrator participated in COMP II. Identification of the Applicants 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

During COMP II, CAB analyst confirmed Applicants and 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 Applicants and Administrator. Report sent via email and informed to return sign copy to CAB by end of business day.
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2023
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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