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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610674
Report Date: 03/07/2025
Date Signed: 03/07/2025 11:34:33 AM

Document Has Been Signed on 03/07/2025 11:34 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
CENTRALIZED APP UNIT, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:EVERETT BOARD AND CARE INCFACILITY NUMBER:
197610674
ADMINISTRATOR/
DIRECTOR:		BUTLER, SALVACIONFACILITY TYPE:
740
ADDRESS:8559 BOTHWELL RDTELEPHONE:
(562) 232-6714
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 6CENSUS: 4DATE:
03/07/2025
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Licensee/administrator Salvacion ButlerTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Facility Type: RCFE
Application Type: CHOW
Capacity: 6
Census (if any clients in care): 4
COMP II Participants: Licensee/administrator Salvacion Butler
Interview Method: Telephone interview

On 3/7/2025, 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
SUPERVISORS NAME: Tammy Edwards
LICENSING EVALUATOR NAME: Vanessa Contreras
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2025
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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