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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530229
Report Date: 08/13/2024
Date Signed: 10/10/2024 12:27:37 PM

Document Has Been Signed on 10/10/2024 12:27 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:MJ SENIOR HOMECARE SERVICES LLCFACILITY NUMBER:
365530229
ADMINISTRATOR/
DIRECTOR:		CHANIKORNPRADIT, MABELFACILITY TYPE:
740
ADDRESS:2172 N MAGNOLIA AVENUETELEPHONE:
(917) 459-1710
CITY:RIALTOSTATE: CAZIP CODE:
92377
CAPACITY: 6CENSUS: DATE:
08/13/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Chanikornpradit, MabelTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Facility Type: RCFE
Application Type: Initial
Capacity: 6
Method: Telephone call with CAB
COMP II Participants: Chanikornpradit, Mabel

On 8/13/24, the applicant/administrator participated in COMP II at CAB via telephone call with analyst at CAB. Identification of the applicant and administrator was verified by confirming driver’s license number. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB.

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: Morrison Ambrose
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2024
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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