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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006091
Report Date: 01/14/2022
Date Signed: 01/14/2022 02:25:10 PM

Document Has Been Signed on 01/14/2022 02:25 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:PRISTINE HOME CAREFACILITY NUMBER:
306006091
ADMINISTRATOR:ALVARADO, MARY JEANFACILITY TYPE:
740
ADDRESS:9252 PACIFIC AVETELEPHONE:
(714) 749-7237
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: DATE:
01/14/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Mary Jean Alvarado and TIME COMPLETED:
01:45 PM
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Facility Type: RCFE Application Type: INITL Capacity: 6 COMP II Participants: Alvarado, Mary Jean (Administrator) and Alvarado, Rod (Corporate Board Member) Interview Method: Telephone interview
On 1/14/22, applicant/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 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 & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Julia Kim
LICENSING EVALUATOR NAME: Bailey Humes
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2022
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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