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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603633
Report Date: 06/21/2023
Date Signed: 06/21/2023 10:31:33 AM

Document Has Been Signed on 06/21/2023 10:31 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:ALONDRA GUEST MANOR INCFACILITY NUMBER:
198603633
ADMINISTRATOR:KAYA, IWONAFACILITY TYPE:
740
ADDRESS:15203 ALONDRA BLVDTELEPHONE:
(714) 228-1098
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 6CENSUS: 6DATE:
06/21/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:SKOMORUCHA, STEFANIE, Applicant
KAYA, IWONA, Administrator. 		TIME COMPLETED:
10:25 AM
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Component II completion: Successful

Facility Type: Residential Care Facility for Elderly (RCFE)
Application Type: Change in Ownership (CHOW)
Capacity: 6
Census (if any clients in care): 6
COMP II Participants: SKOMORUCHA, STEFANIE, Applicant
KAYA, IWONA, Administrator
Interview Method: Telephone interview

On June 21, 2023 at 9L30 AM, Applicant and 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.

During COMP II, CAB Analyst confirmed Applicant and 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/Staff Needs
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing Readiness

Exit interview conducted with Applicant and Administrator. Report sent via email and informed to send sign copy back to CAB by end of business day.
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2023
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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