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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603655
Report Date: 05/09/2023
Date Signed: 05/09/2023 12:00:03 PM

Document Has Been Signed on 05/09/2023 12:00 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 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:ALTA VISTA CARE HOMEFACILITY NUMBER:
198603655
ADMINISTRATOR:ENRIQUEZ,ALMA/STINSON,NICOFACILITY TYPE:
740
ADDRESS:5349 N. OAKBANK AVE.TELEPHONE:
(626) 587-0088
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY: 6CENSUS: 0DATE:
05/09/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Alma Enriquez, Applicant/Administrator
Nicole Stinson, Applicant/Administrator		TIME COMPLETED:
11:50 AM
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Component II completion: Successful

Facility Type: Residential Care Facility for Elderly (RCFE)
Application Type: Initial
Capacity: 6
Census (if any clients in care): none
COMP II Participants: Alma Enriquez, Applicant/Administrator
Nicole Stinson, Applicant/Administrator
Interview Method: Telephone interview

On May 9, 2023 at 10:40 AM, Applicants and Administrators participated in COMP II. Identification of the Applicants and Administrators was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Applicants and Administrators 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 Applicants 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
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing Readiness

Exit interview conducted with Applicants and Administrators. Emailed copy of report pdf and informed to return sign copy to CAB by end of business day today.
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2023
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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