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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209484
Report Date: 10/02/2024
Date Signed: 10/02/2024 11:43:51 AM

Document Has Been Signed on 10/02/2024 11:43 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:REDUBLA SENIORS CAREHOMEFACILITY NUMBER:
107209484
ADMINISTRATOR/
DIRECTOR:		REDUBLA, JENNIFERFACILITY TYPE:
740
ADDRESS:8455 N ARMSTRONG AVETELEPHONE:
(559) 939-3814
CITY:CLOVISSTATE: CAZIP CODE:
93619
CAPACITY: 6CENSUS: DATE:
10/02/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Jennifer RedublaTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Facility Type: RCFE
Application Type: Initial
Capacity: 6
Census (if any clients in care):
COMP II Participants: Jennifer Redubla
Interview Method: Telephone interview

On October 2, 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.Activities in home/ COVID precautions

3. Staffing requirements & Training

4. Pre Licensing inspection readiness

SUPERVISORS NAME: Julia Kim
LICENSING EVALUATOR NAME: Dianne Ramos
LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2024
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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