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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005986
Report Date: 11/30/2021
Date Signed: 11/30/2021 09:39:32 AM

Document Has Been Signed on 11/30/2021 09:39 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:ACTIVCARE LAGUNA HILLSFACILITY NUMBER:
306005986
ADMINISTRATOR:SHETTER, TODD A.FACILITY TYPE:
740
ADDRESS:25200 PASEO DE ALICIATELEPHONE:
(858) 565-4424
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY: 72CENSUS: DATE:
11/30/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:TODD SHETTER
PATRICIA MILLER		TIME COMPLETED:
09:35 AM
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Facility Type: RCFE
Application Type: INITIAL
Capacity: 0072
Census (if any clients in care):

COMP II by CAB successfully completed

Method: Telephone call


COMP II Participant: TODD SHETTER AND PATRICIA MILLER

Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. Identification of the applicant and administrator was verified by photo ID . During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Staff qualifications and responsibilities
3. Applicant and Administrator qualifications
4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions
5. Grievances, Complaints, Community resources
6. Physical plant, food service
7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of property
SUPERVISORS NAME: Mirella Quaranta
LICENSING EVALUATOR NAME: Stefania Fonteno
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2021
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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