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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000888
Report Date: 04/04/2022
Date Signed: 04/05/2022 01:19:32 PM

Document Has Been Signed on 04/05/2022 01:19 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:CROSS CREEK COTTAGEFACILITY NUMBER:
306000888
ADMINISTRATOR:WINIFRED WILSONFACILITY TYPE:
740
ADDRESS:138 EAST 18TH ST.TELEPHONE:
(949) 722-1014
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY: 10CENSUS: 9DATE:
04/04/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Winifred WilsonTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced site visit to the facility on this date for the purpose of delivering an Amended Complaint report originally issued on 10/28/2021. The Report is being amended to change the findings from "Unsubstantiated" to "Substantiated ".

LPA arrived at the facility and met with Administrator Winifred Wilson and reason for visit was explained.

Exit interview was conducted with AD Wilson and a copy of this LIC809 report will be emailed, along with copies of Amended reports.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2022
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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