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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601109
Report Date: 11/05/2021
Date Signed: 11/05/2021 03:54:56 PM

Document Has Been Signed on 11/05/2021 03:54 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:KASA JOMIFACILITY NUMBER:
415601109
ADMINISTRATOR:HUERTAS, JOBELLEFACILITY TYPE:
740
ADDRESS:264 SOUTHCLIFF AVENUETELEPHONE:
(209) 914-2201
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 4CENSUS: DATE:
11/05/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Jobelle, Huertas, Kaycee HuertasTIME COMPLETED:
03:54 PM
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Component II completion: Successful

Facility Type: RCFE
Application Type: Initial
Capacity: 4
Census (if any clients in care): 0
COMP II Participants: Jobelle Huertas (Administrator/ Applicant/licensee); Kaycee Huertas (applicant/licensee)
Interview Method: Telephone interview

On 11/5/2021, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. 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: Mirella Quaranta
LICENSING EVALUATOR NAME: Susan Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2021
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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