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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000130
Report Date: 12/10/2021
Date Signed: 12/10/2021 12:09:16 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: 0DATE:
12/10/2021
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator Ana Shuman and Carmen RodriguezTIME COMPLETED:
12:15 PM
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Licensing Program Analyst Michelle Reed conducted an announced case management visit to close the facility. Upon arrival, LPA met with Licensee Ana Shuman and Carmen Rodriguez. A tour of the physical plant was conducted and there were no residents present. The last resident moved out on 11/7/21 and that was the date of closure.

There were a total of 5 resident's relocated. Proper notice was given and assistance was given for placement. The names of all residents and their relocation location was provided.

Ms. Shuman understands that her facility is officially closed as of today's date and that if she wishes to operate in the future, she will have to apply for a new License.

An exit interview was conducted and a copy of this report was provided to Ms. Shuman.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
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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