<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300606676
Report Date: 11/06/2023
Date Signed: 11/06/2023 05:17:58 PM


Document Has Been Signed on 11/06/2023 05:17 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:
11/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:55 PM
MET WITH:Lourdes Rogers, Elizabeth LutzTIME COMPLETED:
05:25 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced to the facility. LPA received a report from the Licensee and Administrator that the facility was closing and they surrender the license. LPA met the Licensee Lourdes Rogers and Administrator Elizabeth Lutz. LPA and Administrator toured the facility. LPA verified the facility has no residents. Licensee surrendered the license. LPA will close the facility tomorrow 11/7/2023 in the computer system. LPA explained to the Licensee and Administrator that they will not receive a notice the facility is closed, both stated they understood. No deficiencies observed. Facility is now closed. 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: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1