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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610470
Report Date: 10/10/2023
Date Signed: 10/10/2023 11:17:08 AM

Document Has Been Signed on 10/10/2023 11:17 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:BIG HEARTS RESIDENTIAL LIVINGFACILITY NUMBER:
197610470
ADMINISTRATOR:BOTE, ELAINE P.FACILITY TYPE:
740
ADDRESS:22901 CANTLAY STTELEPHONE:
(818) 914-4254
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY: 6CENSUS: DATE:
10/10/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:ELAINE P. BOTETIME COMPLETED:
11:30 AM
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Facility Type: RCFE
Application Type: CHOW
Capacity: 6
Census (if any clients in care):
COMP II Participants: ELAINE BOTE, APPLICANT/ADMINISTRATOR
Interview Method: Telephone interview

On 10/10/23, 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
SUPERVISORS NAME: Mirella Quaranta
LICENSING EVALUATOR NAME: Stefania Fonteno
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2023
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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