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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371689
Report Date: 07/03/2024
Date Signed: 07/03/2024 01:17:23 PM

Document Has Been Signed on 07/03/2024 01:17 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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:TRF ANNE BROUSSARD ECEFACILITY NUMBER:
304371689
ADMINISTRATOR/
DIRECTOR:		MEJICO, DANETTEFACILITY TYPE:
860
ADDRESS:1825 WEST CIVIC CENTER DRIVETELEPHONE:
(714) 333-0199
CITY:SANTA ANASTATE: CAZIP CODE:
92703
CAPACITY: 47TOTAL ENROLLED CHILDREN: 47CENSUS: DATE:
07/03/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Danette Mejico,CPOTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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LIcensing Program Analyst (LPA) P Rivas conducted a case management visit and met with Danette Mejico in order to include the documents missing prior to LPA being able to license facility.
The documents needed are;
1. waivers that include facility sketches
2. Control of Property, missing the exhibits to show which rooms are leased from the City.

Applicant/Licensee Representative Danette Mejico understands that all proof of corrections must be provided to the Department within 30 days, or the application may be denied.
SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Pat Rivas
LICENSING EVALUATOR SIGNATURE: DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2024
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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