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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850199
Report Date: 07/21/2021
Date Signed: 07/21/2021 03:29:35 PM

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:HOME SWEET HOME DUVALI DRFACILITY NUMBER:
565850199
ADMINISTRATOR:VALENCIA, GLORIA P.FACILITY TYPE:
740
ADDRESS:36 DUVALI DRTELEPHONE:
(805) 659-4427
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:6CENSUS: DATE:
07/21/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Shamin Mohamed, Licensee; Gloria Valencia, AdministratorTIME COMPLETED:
03:20 PM
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Facility Type: RCFE
Application Type: Initial
Capacity: 6
Census (if any clients in care): No clients, but there are tenants and notice has been given.

Method: Telephone call with CAB
COMP II Participants: Shamin Mohamed, Licensee; Gloria Valencia, Administrator
Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed.

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: Victoria ChristiansenTELEPHONE: (916) 651-7844
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
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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