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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209181
Report Date: 09/27/2021
Date Signed: 09/27/2021 02:05:24 PM

Document Has Been Signed on 09/27/2021 02:05 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:CROMWELL HAVENFACILITY NUMBER:
107209181
ADMINISTRATOR:SANDONE, RONALD J.FACILITY TYPE:
740
ADDRESS:5787 W. CROMWELL AVE.TELEPHONE:
(925) 470-9712
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY: 6CENSUS: 0DATE:
09/27/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Percival Tobias, Ronald J. Sandone, Yolanda CastigadorTIME COMPLETED:
01:30 PM
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Component II completion: Successful
Facility Type: RCFE Application Type: INITL Capacity: 6
COMP II Participants: Percival Tobias (Board Member), Ronald J. Sandone (Administrator), and Yolanda Castigador (Secondary administrator)
Interview Method: Telephone.
On 9/27/2021, applicant and administrators 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 the understanding of the California Code Title 22 Regulations. 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
SUPERVISORS NAME: Julia Kim
LICENSING EVALUATOR NAME: Bailey Humes
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2021
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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