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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
304312243
Report Date:
07/26/2019
Date Signed:
08/14/2019 02:29:20 PM
COMPREHENSIVE INSPECTION
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
750 THE CITY DRIVE, SUITE 250
ORANGE
,
CA
92868
FACILITY NAME:
LEE, KYUNG AE
FACILITY NUMBER:
304312243
ADMINISTRATOR:
LEE, KYUNG AE
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
(213) 700-3828
CITY:
BUENA PARK
STATE:
CA
ZIP CODE:
90621
CAPACITY:
14
CENSUS:
0
DATE:
07/26/2019
TYPE OF VISIT:
Annual/Random
UNANNOUNCED
TIME BEGAN:
11:30 AM
MET WITH:
TIME COMPLETED:
11:45 AM
NARRATIVE
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SUPERVISOR'S NAME:
Rina Lopez
TELEPHONE:
(714) 703-2808
LICENSING EVALUATOR NAME:
Stacy Torrence
TELEPHONE:
(714) 300-3599
LICENSING EVALUATOR SIGNATURE:
DATE:
08/05/2019
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/05/2019
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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