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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850522
Report Date: 07/19/2024
Date Signed: 07/19/2024 12:41:36 PM


Document Has Been Signed on 07/19/2024 12:41 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
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:SELECT SENIOR LIVING IVFACILITY NUMBER:
565850522
ADMINISTRATOR:HULL, DYLANFACILITY TYPE:
740
ADDRESS:128 ERTEN STREETTELEPHONE:
(805) 777-3855
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: DATE:
07/19/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Dylan Hull, Tracy VarnellTIME COMPLETED:
12:00 PM
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Facility Type: RCFE
Application Type: Initial
Capacity: 6
Census (if any clients in care): 0
COMP II Participants: Dylan Hull (applicant/licensee), Tracy Varnell, Administrator
Interview Method: microsoft teams

On 7/19/24, 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: Mirella QuarantaTELEPHONE: (916) 657-2025
LICENSING EVALUATOR NAME: Susan NguyenTELEPHONE: (916) 657-2600
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024
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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