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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300612929
Report Date: 04/08/2022
Date Signed: 04/08/2022 04:49:36 PM


Document Has Been Signed on 04/08/2022 04:49 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:HARTFORD HOME CAREFACILITY NUMBER:
300612929
ADMINISTRATOR:DINO ASUNCIONFACILITY TYPE:
740
ADDRESS:2424 HARTFORD AVETELEPHONE:
(562) 349-4217
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY:6CENSUS: 6DATE:
04/08/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Dino Asuncion, AdministratorTIME COMPLETED:
05:00 PM
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LPA, Kathrina Chin met with Asuncion Dino, Administrator for the purpose a case management visit. Ms. Asuncion Dino reported that she is selling this facility and that she will make sure to provide a 60 day notice for her intent to sell the facility and will provide the appropriate information on the letter. Also, Ms. Dino said that the Ombudsman will be assisting in relocation of all the residents.

An exit interview was conducted and a copy of this report was given to Asuncion Dino, Administrator.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2022
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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