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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850374
Report Date: 07/20/2023
Date Signed: 07/21/2023 09:17:37 AM


Document Has Been Signed on 07/21/2023 09:17 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:HOMELIFE SENIOR LIVING 8FACILITY NUMBER:
565850374
ADMINISTRATOR:NAZARI, SHERRYFACILITY TYPE:
740
ADDRESS:380 ARCTURUS ST.TELEPHONE:
(805) 338-4448
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 0DATE:
07/20/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Deborah Cassar, ApplicantTIME COMPLETED:
09:30 AM
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Component II completion: Successful

Facility Type: Residential Care Facility for Elderly (RCFE)
Application Type: Change in Ownership (CHOW)
Capacity 6
Census (if any clients in care): none
COMP II Participants: Deborah Cassar, Applicant
Interview Method: COMP II Waiver

On July 20, 2023, 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.

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
Note: COMP II waived for this facility. Previous COMPONENT II conducted on July 19, 2023 with Homelife Senior Living 7 - 565850371. Report for this facility sent to Applicant to sign and return to CAB by end of business day.
SUPERVISOR'S NAME: Darla NeeleyTELEPHONE: (916) 651-7817
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: 916-657-2469
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023
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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