<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603438
Report Date: 04/16/2021
Date Signed: 04/16/2021 04:20:49 PM

Document Has Been Signed on 04/16/2021 04:20 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 8-3-91
SACRAMENTO, CA 95814
FACILITY NAME:NAGOMI HOME LLCFACILITY NUMBER:
198603438
ADMINISTRATOR:AYABE, TOKIEFACILITY TYPE:
740
ADDRESS:1128 N FAIRVALLEY AVETELEPHONE:
(626) 404-8798
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY: 6CENSUS: DATE:
04/16/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Tokie AyabeTIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
COMP II by CAB successfully completed
Facility Type: RCFE
Application Type: Initial
Capacity: 6
Census: 0
Method: Telephone call with CAB Analyst
COMP II Participants: Tokie Ayabe, Applicant/Administrator

Tokie Ayabe participated in COMP II via telephone call with analyst Kathleen Carroll at CAB. Identification of Tokie Ayabe was verified by photo ID that was submitted with the application. During COMP II, Tokie Ayabe confirmed the understanding of Title 22. Component II was successfully completed. Tokie Ayabe has been advised to transmit signed LIC 809 to CAB.
SUPERVISORS NAME: Julia Kim
LICENSING EVALUATOR NAME: Kathleen Carroll
LICENSING EVALUATOR SIGNATURE: DATE: 04/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1