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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530311
Report Date: 01/17/2025
Date Signed: 01/22/2025 11:26:51 AM

Document Has Been Signed on 01/22/2025 11:26 AM - 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:ST PIO HOME FOR THE ELDERLY LLCFACILITY NUMBER:
365530311
ADMINISTRATOR/
DIRECTOR:		GATCHALIAN, KRISTELLEFACILITY TYPE:
740
ADDRESS:8863 ORANGE STREETTELEPHONE:
(626) 646-7598
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91701
CAPACITY: 6CENSUS: DATE:
01/17/2025
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Venancio A GatchalianTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Facility Type: RCFE

Application Type: Initial

Capacity: 6

Census (if any clients in care):

Method: Telephone call with CAB

COMP II Participants: Venancio A Gatchalian

On 1/17/2025, 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: Victoria Morales
LICENSING EVALUATOR NAME: Melody Kiang
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2025
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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