<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850268
Report Date: 08/17/2022
Date Signed: 08/17/2022 10:27:08 AM

Document Has Been Signed on 08/17/2022 10:27 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
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:RESIDENCE AT DEAN LLC, THEFACILITY NUMBER:
565850268
ADMINISTRATOR:LIMBO, JOSEPHINEFACILITY TYPE:
740
ADDRESS:4032 DEAN DRIVETELEPHONE:
(805) 654-0580
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY: 5CENSUS: DATE:
08/17/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:JOSEPHINE LIMBOTIME COMPLETED:
10:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Facility Type: rcfe
Application Type: initial
Capacity: 5
Census (if any clients in care):

COMP II by CAB successfully completed

Method: Telephone call


COMP II Participant: josephine limbo

Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. Identification of the applicant and administrator was verified by photo ID . 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: Mirella Quaranta
LICENSING EVALUATOR NAME: Stefania Fonteno
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1