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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000130
Report Date: 10/05/2021
Date Signed: 10/05/2021 01:02:56 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:ANA MARIE'S GUEST HOMEFACILITY NUMBER:
306000130
ADMINISTRATOR:SHUMAN, ANA M.FACILITY TYPE:
740
ADDRESS:1304 E. CHAPMANTELEPHONE:
(714) 744-9555
CITY:ORANGESTATE: CAZIP CODE:
92866
CAPACITY:6CENSUS: 5DATE:
10/05/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Staff Paola OlivaresTIME COMPLETED:
01:15 PM
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Licensing Program Analyst Michelle Reed arrived at the facility to complete Complaint #22-AS-20210901095426 and discuss the closure of the facility. Upon arrival, LPA met with Staff Paola Olivares and Cesar Acevedo Limon. Ms. Shuman was spoken to via telephone.

Ms. Shuman notified LPA Reed on 9/16/21 that she would like to close her facility. Procedures for the closure were provided via email.

On 9/20/21 a letter was provided to the families of 5 residents that the facility would be closing and that assistance with placement would be provided. Ms. Shuman is giving a 60 day notice and would like to see all residents moved by the end of November. Alliance Eldercare is working with families for placement and Licensee Carmen Rodriguez who is a friend of Ms. Shuman is also assisting.

On today's date, a copy of the facility roster was provided. No resident's have been relocated at this time. Ms. Shuman was told and is reminded that she must keep LPA updated with the closure and move of the residents. Once all residents move, a list will need to be provided to Licensing with the location and phone number of the facility the residents moved to. The Department will need to conduct a closure visit at the facility as soon as all residents are moved.

An exit interview was conducted and a copy of this report was provided.




SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
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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