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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006317
Report Date: 05/04/2023
Date Signed: 05/08/2023 02:05:19 PM

Document Has Been Signed on 05/08/2023 02:05 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:FAITHFUL HOME OF ROSSMOOR, AFACILITY NUMBER:
306006317
ADMINISTRATOR:KHOLOMA, THERESAFACILITY TYPE:
740
ADDRESS:2851 BOSTONIAN DRTELEPHONE:
(714) 300-8055
CITY:ROSSMOORSTATE: CAZIP CODE:
90720
CAPACITY: 6CENSUS: 0DATE:
05/04/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Theresa Kholoma, Applicant/AdministratorTIME COMPLETED:
02:30 PM
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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: Theresa Kholoma, Applicant/Administrator
Interview Method: Telephone interview

On May 4, 2023, 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/ 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: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2023
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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