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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881282
Report Date: 01/13/2022
Date Signed: 01/13/2022 02:47:20 PM

Document Has Been Signed on 01/13/2022 02:47 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:AL HAYBA HOMEFACILITY NUMBER:
361881282
ADMINISTRATOR:HAMED, EBRAHEEMFACILITY TYPE:
740
ADDRESS:13849 COBBLESTONE CTTELEPHONE:
(786) 564-3771
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY: 6CENSUS: DATE:
01/13/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Ebraheem Hamed, Applicant/AdministratorTIME COMPLETED:
02:40 PM
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Facility Type: RCFE
Application Type: Initial
Capacity: 6
Census (if any clients in care): 2 individuals currently residing at property that will be moving out prior to the pre-licensing inspection.

Method: Telephone call with CAB
COMP II Participants: Ebraheem Hamed, Applicant/Administrator
Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. 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: Jude De La Concepcion
LICENSING EVALUATOR NAME: Victoria Christiansen
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2022
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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