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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610251
Report Date: 05/13/2022
Date Signed: 05/13/2022 10:03:08 AM

Document Has Been Signed on 05/13/2022 10:03 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:MONDELL PINE MANOR IFACILITY NUMBER:
197610251
ADMINISTRATOR:SOLIS, CANDICEFACILITY TYPE:
740
ADDRESS:39046 MONDELL PINE AVE.TELEPHONE:
(818) 332-6150
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 6CENSUS: DATE:
05/13/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Solis, CandiceTIME COMPLETED:
09:40 AM
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Facility Type: RCFE
Application Type: Initial
Capacity: 6
Method: Telephone call with CAB

Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. Identification of the applicant/administrator was verified by correctly answering identity verification questions. During COMP II, applicant/administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant has been advised to transmit signed LIC 809 with copy of photo ID to CAB.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Staff qualifications and responsibilities
3. Applicant and Administrator qualifications
4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions
5. Grievances, Complaints, Community resources
6. Physical plant, food service
7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of property
SUPERVISORS NAME: Julia Kim
LICENSING EVALUATOR NAME: Nicole Rouse
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2022
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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