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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000838
Report Date: 02/24/2022
Date Signed: 02/24/2022 09:45:48 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/24/2022 09:45 AM - 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:A TO Z GARDEN VILLAFACILITY NUMBER:
306000838
ADMINISTRATOR:GROCHULSKI ZOFIA, ANNAFACILITY TYPE:
740
ADDRESS:23666 VERONATELEPHONE:
(949) 922-0025
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:6CENSUS: 0DATE:
02/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Zofia GrochulskiTIME COMPLETED:
09:55 AM
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Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing a 1 year required inspection. LPA arrived at facility was greeted at the door by administrator and granted entry. During today’s visit, LPA met with Administrator Zofia Grochulski and explained the reason for visit. LPA toured the facility and inspected the physical plant of the facility, no residents were observed at facility. LPA was informed there are no residents currently residing at facility and only occupant is administrator. LPA was informed that nothing has changed with the facility since last annual of 2019 and facility has no residents and the last resident that resided at facility was January of 2016. Licensee will contact Community Care Licensing (CCL) to inform of when they are ready to accept new residents or if there are any changes with the license.

At this time there were no deficiencies to report in the facility. As noted above, Licensee will contact CCLD once residents are being admitted. In an effort to update the facility file, the Administrator is required to submit to the licensing agency a copy of the following:

- An updated Personnel Report (LIC 500).

- Copy of Administrator Certificate.

This report was reviewed with administrator and a copy of this LIC809 report was provided

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022
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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