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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603604
Report Date: 11/08/2022
Date Signed: 11/08/2022 10:09:07 AM

Document Has Been Signed on 11/08/2022 10:09 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:A BELOVED HOME OF DIAMOND BARFACILITY NUMBER:
198603604
ADMINISTRATOR:DUONG, MY MYFACILITY TYPE:
740
ADDRESS:454 S ROCK RIVER RDTELEPHONE:
(626) 899-6999
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 6CENSUS: DATE:
11/08/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:My My Duong-Managing Member/AdministratorTIME COMPLETED:
09:55 AM
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Facility Type: RCFE
Application Type: Initial
Capacity: 6
COMP II Participant: My My Duong, Managing Member/Administrator
Interview Method: Telephone interview

On 11/8/22, applicant/administrator participated in COMP II. Identification of the applicant/administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant/administrator confirmed the understanding of the California Code Title 22 Regulations. 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/CPMB associations & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Mirella Quaranta
LICENSING EVALUATOR NAME: Anna Barrios
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2022
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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