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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850406
Report Date: 06/07/2024
Date Signed: 06/07/2024 04:32:04 PM


Document Has Been Signed on 06/07/2024 04:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRALIZED APP UNIT, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:SALLY RESIDENTIAL CARE HOME 3FACILITY NUMBER:
565850406
ADMINISTRATOR:AKINMADE, OLUWATOSINFACILITY TYPE:
740
ADDRESS:953 ANADANTE COURTTELEPHONE:
(818) 274-1809
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:6CENSUS: 6DATE:
06/07/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Joseph Jose and Oluwatosin AkinmadeTIME COMPLETED:
04:26 PM
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Facility Type: RCFE
Application Type: CHOW
Capacity: 6
Census (if any clients in care): 6
COMP II Participants: Joseph Jose (Corporate Board Member) & Oluwatosin Akinmade (Administrator)
Interview Method: Virtual interview via Microsoft Teams


On June 07, 2024, applicant/administrator participated in COMP II. Identification of the applicant 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. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/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
SUPERVISOR'S NAME: Darla NeeleyTELEPHONE: (916) 651-7817
LICENSING EVALUATOR NAME: Diamond LawTELEPHONE: (916) 657-3571
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2024
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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