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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300600977
Report Date: 02/22/2021
Date Signed: 02/22/2021 04:28:14 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:TOWN & COUNTRYFACILITY NUMBER:
300600977
ADMINISTRATOR:STEPHENIE JUKICFACILITY TYPE:
741
ADDRESS:555 E. MEMORY LANETELEPHONE:
(714) 547-7581
CITY:SANTA ANASTATE: CAZIP CODE:
92706
CAPACITY:240CENSUS: 143DATE:
02/22/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Stephanie JukicTIME COMPLETED:
04:45 PM
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Licensing Program Analysts (LPAs) Kimberly Lyman and Jenifer Tirre conducted an unannounced health and safety visit to the facility. LPAs were greeted and granted entry by Director of Residential Services (DRS) Stephanie Jukic and explained the reason for the visit.
On this day, DRS Jukic reported a resident death to to licensing. 911 was called and Santa Ana Fire as well as the local police department responded. Coroner's office was on scene as well. During the visit, LPAs toured the facility with DRS Jukic and observed residents engaged in socially distanced activities as well as relaxing in the courtyard. No immediate health and safety concerns noted. LPAs reviewed health and safety regulations with DRS Jukic as well as gathered information regarding the incident.


No citations noted during visit however further investigation will be required.





Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2021
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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