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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006526
Report Date: 05/31/2024
Date Signed: 05/31/2024 03:53:59 PM

Document Has Been Signed on 05/31/2024 03:53 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
CENTRALIZED APP UNIT, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:KAELA'S HOME FOR ELDERLYFACILITY NUMBER:
306006526
ADMINISTRATOR/
DIRECTOR:		DUMALIANG, CZARINE SFACILITY TYPE:
740
ADDRESS:24176 MCOY ROADTELEPHONE:
(310) 308-0925
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 0DATE:
05/31/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Czarina Dumaliang, Administrator/LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Facility Type: RCFE
Application Type:Initial
Capacity:6
Census (if any clients in care):N/A
COMP II Participants: Name, Title
Interview Method: Telephone interview


On [05/31/2024], applicant(s)/administrator participated in COMP II for the below pending facilities: [list out all of the applicable pending applications in the following format: FACILITY NAME/FACILITY #, ex. Front Street Facility/123456789, Back Alley Facility/987654321, etc…]. Identification of the applicant(s) and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant(s) and 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 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: LaVill Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2024
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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