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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603657
Report Date: 04/28/2023
Date Signed: 05/01/2023 10:02:27 AM

Document Has Been Signed on 05/01/2023 10:02 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:HOME 'R USFACILITY NUMBER:
198603657
ADMINISTRATOR:ISIDRO, MARGARITAFACILITY TYPE:
740
ADDRESS:10423 TRABUCO ST.TELEPHONE:
(562) 376-0298
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 6CENSUS: 0DATE:
04/28/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Margarita Isidro CEO/AdministratorTIME COMPLETED:
10:35 AM
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Component II completion: Successful

Facility Type: RCFE
Application Type: INITIAL
Capacity: 6
Census (if any clients in care): 0
COMP II Participants: Margarita Isidro - CEO/Administrator
Interview Method: Telephone interview

On April 28, 2023, 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 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 the 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: Tracy Thompson
LICENSING EVALUATOR NAME: Ricmar Soriano
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2023
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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