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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604611
Report Date: 02/07/2023
Date Signed: 02/07/2023 02:43:06 PM

Document Has Been Signed on 02/07/2023 02:43 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:IDEAL HOME CAREFACILITY NUMBER:
374604611
ADMINISTRATOR:HULSEY, JOSEFINA I.FACILITY TYPE:
740
ADDRESS:3337 STOCKMAN STREETTELEPHONE:
(619) 519-0025
CITY:NATIONAL CITYSTATE: CAZIP CODE:
91950
CAPACITY: 6CENSUS: 0DATE:
02/07/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Josefina Hulsy, Applicant/AdministratorTIME COMPLETED:
02:35 PM
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Component II completion: Successful

Facility Type: Residential Care Facility for Elderly (RCFE)
Application Type: Initial
Capacity: 6
Census (if any clients in care): none
COMP II Participants: Josefina Hulsey, Applicant/Administrator
Interview Method: Telephone interview

On February 7, 2023 at 2:00 PM, Applicant/Administrator participated in COMP II. Identification of the Applicant/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.

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

Exit interview conducted with Applicant/Administrator. A copy of report sent via pdf email and informed to return sign copy to CAB by end of business day
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2023
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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