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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313614
Report Date: 03/10/2020
Date Signed: 03/10/2020 02:46:30 PM

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:SIMPSON, MICHELLEFACILITY NUMBER:
304313614
ADMINISTRATOR:SIMPSON, MICHELLEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 650-8174
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY:14CENSUS: 9DATE:
03/10/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Michelle SimpsonTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Jungmi Han and LPA Carmen Odom conducted case management inspection. LPAs toured the facility inside and outside including off limit areas and the floor and yard plan (LIC 999) were verified. During today's inspection LPA observed 3 infants and 6 preschool children with husband. Licensee was interviewing a person in the dinning area. LPA reviewed caregiver background status of an interviewee and verified she received criminal record and child abuse index clearance and it is currently active at another licensed facility.

A review of adult records indicates that all facility residents, staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.
During today’s inspection the home and grounds were toured, and the licensee was operating within the licensed capacity.

There were no Title 22 deficiencies cited during today's inspection.

An exit interview was completed with licensee. The report was reviewed and discussed. Appeal Rights and deficiencies were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days.

The facility representative was informed that the “Notice of Site Visit” must be posted for 30 consecutive days. The “Notice of Site Visit” must be posted on or adjacent to the door. Failure to post will result in Civil Penalties of $100.00.
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Jung Mi HanTELEPHONE: (714) 309-7211
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2020
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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