Follow-up·April 19, 2023

Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit. LPA Martinez met with Christine Torres and explained the purpose of the visit. The purpose of the visit today, is in response to a change of Administrator and a corporation change- LIC 200 application follow up. LPA Martinez informed Christine Torres an LIC 200 application will need to be submitted to the Centralized Application Bureau (CAB), and LPA Martinez provided CAB's website and telephone number information. https://www.cdss.ca.gov/inforesources/community-care/ascp-centralized-application-units https://www.cdss.ca.gov/cdssweb/entres/forms/English/LIC200.pdf CAB Phone number: (833) 827-6084 Christine reported she is working on submitting the LIC 200 application to CAB. In addition, the following Administrator documentation will need to be submitted to CCLD: LIC 200 from licensee requesting administrator Change Board Resolution for new administrator if corporation LIC 308 Designation of Facility Responsibility LIC 501 Personal Record LIC 503 Health Screening Report LIC 500 Personnel Report Administrator Certificate An exit interview was conducted, and a copy of this report was provided to Christine.