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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300606676
Report Date: 08/24/2023
Date Signed: 08/24/2023 05:23:20 PM


Document Has Been Signed on 08/24/2023 05:23 PM - 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:CHARLOU GUEST HOME #3FACILITY NUMBER:
300606676
ADMINISTRATOR:LOURDES ROGERSFACILITY TYPE:
740
ADDRESS:1767 W. BRENTWOOD PLACETELEPHONE:
(714) 491-2840
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 0DATE:
08/24/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Lourdes Rogers, Elizabeth LutzTIME COMPLETED:
05:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced case management visit. LPA was contacted by the Licensee who reported the facility has no residents and the facility is going to undergo renovations. LPA met with the Licensee and Administrator Elizabeth Lutz and explained the reason for the visit. The Licensee reported that the facility footprint (layout) will not change and no rooms are going to be added. LPA informed the Licensee that any changes to the layout of the facility including, walls, doors windows and rooms needs to be approved by the Agency. The Licensee stated she understood. The Licensee stated that most of the changes will be cosmetic improvements. LPA and Licensee toured the facility. LPA verified there are no residents living at the facility. LPA informed the Licensee that all applicable city building code ordinances must be followed. LPA informed the Licensee that the facility could be visited by Licensing and is still subject to Title 22 regulations, the Licensee stated she understood. No deficiencies were observed during the visit. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
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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